patient covid pre-screening form.

Please fill out within 48 hours of receipt of our 1 week pre-screening reminder email.

Download a fillable PDF version of the COVID pre-screening form,
fill it out, save it and email it directly to
office@whitetoothdental.ca

Click to download a fillable PDF

OR use the webform below:

Form Introductory Text

Patient Information

Are you under 12 years old ?

Screening Questions

1. In the last 10 days have you experienced any of the following symptoms?

  • Fever and/or chills - Temperature of 37.8oC/100oF or higher.
  • Cough or barking cough (croup)
  • Shortness of breath
  • Decrease or loss of smell or taste

SELECT “NO” if:

You are fully vaccinated and not immune compromised OR under 12 years old and not immune compromised:
AND experienced the symptom(s) over 5 days ago
AND symptom(s) have been improving over 24h
AND you do not have a fever

OR

You are symptomatic BUT ALSO tested negative for COVID -19 on a single PCR test or 2 rapid antigen tests (RAT) taken 24-48h apart
AND symptom(s) have been improving over 24h
AND you do not have a fever

OR

You are unvaccinated OR immune compromised:
AND experienced the start of symptom(s) over 10 days ago
AND symptom(s) have been improving over 24h
AND you do not have a fever

Select

2. In the last 10 days have you experienced any of the following symptoms?

  • Runny or stuffy/ congested nose
  • Sore throat
  • Headache
  • Muscle aches/ joint pain
  • Fatigue
  • Nausea, vomiting and/or diarrhea

SELECT “NO” if:

You are fully vaccinated and not immune compromised or under 12 years old and not immune compromised:
AND experienced the symptom(s) over 5 days ago
AND symptom(s) have been improving over 24h (48h for gastrointestinal symptoms)
AND you do not have a fever

OR

You are symptomatic BUT ALSO tested negative for COVID -19 on a single PCR test or 2 rapid antigen tests (RAT) taken 24-48h apart
AND symptom(s) have been improving over 24h (48h for gastrointestinal symptoms)
AND you do not have a fever

OR

You are unvaccinated OR immune compromised
AND experienced the start of symptom(s) over 10 days ago
AND symptom(s) have been improving over 24h (48h for gastrointestinal symptoms)
AND you do not have a fever

Select One

3. In the last 14 days, have you travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)?

4. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home due to an outbreak or contact tracing)?

5. In the last 10 days, have you tested positive for COVID-19?

SELECT “NO” if:

You are fully vaccinated OR under 12 years of age and not immune compromised and the test was more than 5 days ago

Choose One

6. Do any of the following apply?

  • You live with someone who is currently isolating because of a positive COVID19 test
  • You live with someone who is currently isolating because of COVID-19 symptoms
  • You live with someone who is waiting for COVID-19 test results

SELECT “NO” if:

You tested positive for COVID-19 (on a lab-based PCR test, rapid antigen test or home-based self-testing kit) within the last 90 days AND have already completed your isolation period

.

White Tooth Dental COVID Safety Protocols

  • EVERY PERSON (patient or otherwise) MUST be wearing a mask to enter and for the duration of their visit (except during treatment)
  • Please sanitize hands upon entering and departing at our sanitation station
  • Your temperature will be taken
  • Please do not bring a guest with you (special exceptions will be considered)
  • If you are early OR the waiting room is fully occupied when you arrive: please exit the building (please try not to linger in the hallway) and wait in your car until your appointment OR wait outside the building, and call the office when you arrive. We will call you back once the waiting room is clear and your room is ready for you.
  • If we don't have a MOBILE NUMBER for you, please provide it here, in case we have to call you back into the office

Do you agree to comply with our in-office safety protocols?