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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:

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

Delirium

Unexplained increase number of falls

Acute functional decline

Worsening chronic conditions

Not sure

None of the above

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