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BATHURST FINCH DENTAL OFFICE

Accepting new patients & same day emergencies

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First Name

Last Name

Select a date

If you are taking any new medications or if there is a change in your medications / medical conditions since your last visit please list them:

Have you had close contact with anyone with acute respiratory illness or anyone who has traveled outside of Ontario within the last 14 days? *

Yes

No

Do you have a confirmed case of COVID 19 or have you had close contact with a confirmed case of COVID-19? *

Yes

No

Do you have any of the following symptoms: * Required

Fever

New onset of cough

Worsening chronic cough

Shortness of breath

Difficulty breathing

Sore throat

Difficulty swallowing

Decrease or loss of taste or smell

Chills

Headaches

Unexplained fatigue / malaise / muscle aches

Nausea/vomiting, diarrhea, abdominal pain, pink eye (conjunctivitis)

Runny nose/ nasal congestion without other known cause

None of the above

If you are 70 years old or older and experiencing any of the following symptoms * Required

Delirium

Unexplained increase number of falls

Acute functional decline

Worsening chronic conditions

Not sure

None of the above

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