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BATHURST FINCH
DENTAL OFFICE
416-229-2444
Accepting new patients & same day emergencies
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COVID-19 Form
Please read carefully and fill in the information prior to your appointment. Thanks!
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
Submit
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