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

Great Smiles are by Choice
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Patient Screening Form

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

Patient Screening Form
1) Did you receive your final (or second) vaccination dose more than 14 days ago? *
Please answer Questions 2 and 3 below only if you responded No to Question 1.
2) Have you traveled outside of Canada in the last 14 days?
3) Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?
4) Do you have any of the following symptoms - Fever and/or chills - New onset of cough or worsening chronic cough - Shortness of breath - Decrease or loss of sense of taste or smell - If adult: 18 years of age: unexplained fatigue/lethargy/malaise/muscle aches (myalgias) - If child: under 18 years of age: nausea/vomiting, diarrhea *
5) Have you tested positive for COVID-19 in the past 10 days or have you been told you should be isolating? *
Please remember to wear a mask to your appointment.
COVID-19: Information about appointments & visitsCLICK HERE