AYLMER FAMILY DENTAL COVID-19 PRE-SCREENING FORM AYLMER FAMILY DENTAL COVID-19 PRE-SCREENING FORMPatient Name:* First Last Date of Birth: MM DD YYYY 1. Have you tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE*YesNo2. Have you travelled outside of Canada in the past 14 days?*YesNo3. Have you had close contact with anyone self-isolating because of a determined risk of COVID-19?*YesNo4. 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 or muscle aches nausea/vomiting, diarrhea, abdominal pain pink eye runny nose or nasal congestion without other known cause none of the above 5. Are you 70 years of age or older?*YesNoHave you experienced any of the following symptoms:* Delirium Unexplained or increased number of falls Acute functional decline Worsening of chronic conditions None of the above * I verify that the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have my dental treatment completed during the COVID-19 pandemic. * I will notify Aylmer Family Dental shoud I develop any of the above symptoms prior to my scheduled appointment. Signature*
