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Contact form

Name

DENTIST REFERRAL

Periodontist Referral
Reason for periodontist referral:
IV Sedation Referral
Reason for IV sedation referral:
Orthodontist Referral
Reason for orthodontist referral:
We are introducing:
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Appointment*
Please provide specialist with appropriate details of problem; i.e. urgency, areas of concern, using F.D.I. tooth numbering system.
Indicate any special factors –either dental or medical –such as allergies and medical problems relevant to diagnosis and treatment.
Digital Radiographs*
Radiographs
Select all that applies
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Contact form 1




CHILDREN’S PATIENT FORM

Patients Name
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Address
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Parent Name
Please check any of the following that apply:

Has your child ever had any of the following?

Checkbox

Does your child have or have they ever had any of the following?

Please check any of the following that apply:

For Parents

Dental Insurance

Parent Name ( required for under 18 years )
Use your mouse or finger to draw your signature above

Patient Screening Form

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Q1. Are you immunocompromised?
  • Fever and/or chills tiredness Cough or barking cough Shortness of breath nose Decrease or loss of taste or smell
  • Muscle aches/joint pain Extreme
  • Sore throat
  • Runny or stuffy/congested
  • Headache
  • Nausea, vomiting and/or diarrhea
  • Abdominal pain
  • Pink eye
symptoms
03: Have you been told (by a doctor, health care provider, public health unit, federal border agent. or other government authority} that you should currently be quarantining,isolating or staying at home?
Q4: In the last lO 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?
  • Sanitize their hands
  • Have their temperature taken (depending on the dental office*s policies).
  • undergoing cancer chemotherapy
  • with untreated HIV infection with CD4 T lymphocyte count less than 200
  • with combined primary immunodeficiency disorder
  • on prednisone medication - more than 20 mg per day {or equivalent} for more than 14 days
  • on other immune suppressive medications.
  • you do not have a fever, and
  • your sympLoms have been improving for 24 hours (4B hours if you have nausea, vomiting, and/or diarrhea)

COVID-19 SCREENING FORM

Are you a current or new patient?*
Patient Name*
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Time
:
Question 1: Did you receive your final (or second) vaccination dose more than 14 days ago?*
* A fully immunized individual is defined as any individual >14 days after receiving their second dose of a two-dose COVID-19 vaccine series or their first dose of a one-dose COVID-19 vaccine series (i.e .Johnson and Johnson).
Question 2: Do you have any of the following symptoms?*
Question 3:Have you tested positive for COVID-19 in the past 10 days or have you been told you should be isolating?
Question 4: Have you travelled outside of Canada in the past 14 days?
Question 5: Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?
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