www.sherwooddental.ca - Health Screening Form

Health Screening Form
In an effort to maintain a low-risk health environment in the office and in accordance with the guidelines as set out by the Ontario Ministry of Health, the Royal College of Dentists of Ontario (RCDSO), and the College of Dental Hygienists of Ontario (CDHO), we ask all patients to complete this screening form prior to your appointment. Thank you for your understanding and cooperation.
In the last 7 days, have you or any member of your household experienced any flu-like symptoms (example: fever, sore throat, nausea, vomiting, etc.)*

YesNo
In the last 7 days, have you had a confirmed case of COVID-19 or have you had close contact with a confirmed case of COVID-19?*

YesNo
By signing this document, I acknowledge that the answers I have provided above are true and accurate.
Patient’s (or legal guardian’s) Signature*

Clear
Your digital signature is as legally binding as a physical signature.
Patient Name*

First NameMiddle NameLast Name
Date

MonthDayYear
Date
Should be Empty: