8920 Highway 50, Unit E9, Brampton, ON Phone: 905-915-8988

Patient screening Form

Use this form to screen patients before their appointment and when they arrive for their appointment


Who Answered


Other Specify

Contact method

If other




Identify yourself and explainthe purpose of the call, which is to determine whether there are any special considerations for their dental appointmcent. Have the patient answer the following questions.

Screening Questions Pre-screen In-office

Do you have a fever or have felt hot or feverish anytime in the last two weeks?

Patient temperature at appointment . If elevated , provide mask to patient.

Do you have any of these symptoms: Dry cough? shortness of breath? difficulty breathing? Sore throat? Runny Nose?

Have you experienced a recent loss of smell or taste?

Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk of COVID-19 ?

Have you returned from travel outside of Canada in the last 14 days ?

Have you returned from travel within canada from a location know affected with COVID-19 ?

Are you over the age of 60 ?

Do you have any of the following? Heart disease,lung disease, kidney disease, diabetes, or any auto-immune disorder ?

  • Any “yes” response must be discussed with the managing dentist immediately.

  • When you arrive at the office, you will be asked to:

  • Sanitize your hands.

  • Answer the questions again.

  • Have their temperature taken.

  • May need to complete a form acknowledging the risk of COVID-19.

  • Advice the patient:

  • Only patients are allowed to come to the office

  • If possible, to wait in their car untill their appointment, call the office when they arrive



Patient Acknowledgement: COVID-19 Pandemic Dental Risk

I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. I understand the novel coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. For this reason, it is recommended to stay home and avoid close contact with other people when at all possible.(initial)

I understand the federal and provincial governments have asked individuals to maintain social distancing of a least 2 metres (6 feet) and I recognize it is not possible to maintain this distance while receiving dental treatment.(initial)

I understand that oral surgery/dental procedures can create water and/or blood spray, which is one important way that the novel coronavirus can spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the novel coronavirus.(initial)

I understand that due to the visits of other patients, the characteristics of the novel coronavirus, and the characteristics of dental procedures, that I have an elevated risk of contracting AND SPREADING the novel coronavirus simply by being in the dental office.(initial)

I have been made aware that the Province/Territory of Ontario has, under the current pandemic, has now allowed most dental care but our office is cautious and selectively treating patients based on priority. Dental visits will be limited to only the emergency and urgent treatments as triaged by our treating Dentists. Until few more weeks, we are made aware that our priority would be to first address dental emergencies like, bleeding, trauma, significant infection not responding to antibiotics and pain killers, or to alleviate severe pain that does not respond to antibiotics and pain killers. I confirm that I am OK with your safe and cautious approach at this time and I completely understand that may need to wait longer for definitive treatment.(initial)

I confirm and accept that emergency treatment/consultation provided may not necessarily be representative of the care that would be expected or provided under normal circumstances and may be very limited to only simple emergency care for
now (initial)

I confirm that I do NOT have any TWO OR MORE or the following symptoms of COVID-19: fever, new or worsening cough, sore throat, runny nose or headache.(initial)

I confirm that I have not tested positive for COVID-19.(initial)

I confirm that I am not waiting for the results of a test for COVID-19.(initial)

I confirm that this is not currently a period where I required to self-isolate for 14 days.(initial)

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have proposed dental treatment completed during COVID-19 pandemic period. I affirm and certify that all the information and answers to questions herein are complete, true and correct to the best of my knowledge and belief. I understand that any misrepresentation, falsification, or omission of any facts would lead to public health agency investigation.