Patient Screening Online Form – Belleville Family Dental Care

Medical History New Patient

"*" indicates required fields

First Name*

Last Name*

Email Address*

Phone*

Have you travelled outside of Canada in the past 14 days?*

Yes

Have you tested positive to COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?*

Yes

Do you have any of the following symptoms:
• Fever
• New onset of cough
• Worsening chronic cough
• Shortness of breath
• Difficulty breathing
• Sore throat
• Difficulty swallowing
• Decrease or loss of sense of taste or smell
• Chills
• Headaches
• Unexplained fatigue/malaise/muscle aches (myalgias)
• Nausea/vomiting, diarrhea, abdominal pain
• Pink eye (conjunctivitis)
• Runny nose/nasal congestion without other known cause*

Do you have any of the following symptoms:*

Yes

If you are 70 years of age or older, are you experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?

Yes

CAPTCHA

Medical History New Patient

Belleville Dentistry