Mer Bleue Dental Centre The Orléans Dental Experience Request an Appointment Covid-19 Screening Form COVID-19 SCREENING FORM Are you a current or new patient?* New Patient Current Patient Patient Name* First Last Phone*Email* Question 1: Are you immunocompromised and/or live in a highest-risk congregate care setting?* Yes No Question 2: Do you have any of these symptoms? Choose any or all that are new, worsening and not related to other known causes or conditions.* Fever and/or chills Cough or barking cough Shortness of breath Decrease or loss of taste or smell Muscle aches/joint pain Extreme tiredness sore throat Runny or stuffy/congested nose Headache Abdominal pain Pink eye none Question 3: Have you been told (by a doctor, health care provider, public health unit, federal border agent, or other goverment authority) that you should currently be quarantining, isolating or staying at home?* Yes No Question 4: In the last 10 days, have you tested positive for COVID-19 on a laboratory-based PCR test, rapid molecular test, rapid antigen test or other home-based self-testing kit?* Yes No Date* MM slash DD slash YYYY
