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NORTHMOUNT DENTAL CARE COVID-19 PATIENT SCREENING
Your Full Name
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Do you have any of these symptoms: A Fever, new or worsening cough, new or worsening shortness of breath, sore throat or painful swallowing, or runny nose?
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Yes
No
Have you experienced a recent loss of smell or taste?
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Yes
No
Have you tested positive for COVID-19 in the last 14 days?
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Yes
No
Are you currently within an AHS recommended 14 day self-isolation period?
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Yes
No
Have you been identified as a close contact with a person who has a probable or confirmed case of COVID-19 in the last 14 days?
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Yes
No
Have you returned from travel outside of Canada in the last 14 days?
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Yes
No
Are you over the age of 65?
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Yes
No
Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?
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Yes
No
PLEASE READ:
Please wear a mask to your appointment and hand sanitize upon entry.
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I understand
Please come alone to your appointment unless you are a child or need the assistance of a caregiver.
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I understand
Please leave all non essential belongings in your vehicle (coffee, food, water bottles etc).
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I understand
Upon entry we will perform a temperature check and ask you to fill out a COVID-19 information and treatment consent form.
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I understand
Verify
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Thank you! We will see you soon!
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