In Office Patient COVID Screening Form

MM slash DD slash YYYY
Patient Name:(Required)
Have you travelled outside of the country in the past 14 days? (Whether you have an exemption through border control or not or if you are considered an essential worker)
Are you, or have you in the last 14 days,been in contact with any confirmed COVID-19 positive patients?
Have you tested positive for COVID-19 in the past 3 months?
Do you have a confirmed case of COVID-19 or waiting on test results?
Have you had contact with a confirmed case of COVID-19?
Have you been exposed to anyone who has travelled outside the country in the past 2 weeks and has returned? ( for instance, someone who is quarantining in your home?)

List Symptoms

  • Fever more than 37.8*C
  • 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

Office protocol to follow:

You MUST wear a mask in all public areas while in the office. This includes hallways, as well as the waiting room. Your nose and mouth must be fully covered. You may take your mask off when you enter the Operatory and are seated. If you need a new mask after your procedure, we can provide one for you but you must put your mask back on after exiting the Operatory.

Do you have any of the above symptoms?
Name of Patient:
MM slash DD slash YYYY

Once fully read and reviewed, please make sure that the above document is filled out appropriately. By signing below and submitting this document, we are assuming that it has been read in its entirety. All patient signatures will be verified for authenticity in the office.