369 West Street N., Orillia, ON L3V 5E5
Phone: (705) 326-4351

Great Smiles are by Choice
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Patient Screening Form

Patient Screening Form

This form must be completed between 48 and 24 hours prior to your scheduled appointment.

Patient Screening Form
Have you travelled outside of Ontario in the last 14 days? *
Have you tested positive for Covid-19 or have you had close contact with a confirmed case of Covid-19 without wearing appropriate PPE? *
Do you have a fever, or have you felt feverish anytime in the last two weeks? *
New onset of cough? Worsening chronic cough? Shortness of breath? Difficulty breathing? *
Sore throat? Difficulty swallowing? Decrease or loss of your sense of taste or smell? *
Chills? Headaches? Unexplained fatigue/malaise/muscle aches (myalgia)? *
Nausea? Vomiting? Diarrhea? Abdominal Pain? *
Pink eye (conjunctivitis)? *
Runny nose or nasal congestion without other known cause (e,g, allergies)? *
Are you 70 years of age and experiencing delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions? *
COVID-19: Information about appointments & visitsCLICK HERE