Please fill out the following health questionnaire prior to coming in for your appointment.

OR Download, Fill & Print the questionnaire and bring it to your next appointment.

1 Step 1
Patient Screening Form
Q1: Are you immunocompromised?

Factors such as old age, diabetes and end-stage renal disease are generally not considered immunocompromised. Examples of being immunocompromised include individuals:

  • undergoing cancer chemotherapy
  • with untreated HIV infection with CD4 T lymphocyte count less than 200
  • with combined primary immunodeficiency disorder
  • on prednisone medication – more than 20 mg per day (or equivalent) for more than 14 days
  • on other immune suppressive medications
Q2: Do you have any of these symptoms? Choose any or all that are new, worsening and not related to other known causes or conditions*

Select “No” if all of these apply:

  • you do not have a fever, and
  • your symptoms have been improving for 24 hours (48 hours if you have nausea, vomiting, and/or diarrhea).
Q3: Have you been told (by a doctor, health care provider, public health unit, federal border agent, or other government authority) that you should currently be quarantining, isolating or staying at home?
Q4: In the last 10 days, have you tested positive for COVID-19 on a laboratory-based PCR test, rapid molecular test, rapid antigen test or other home-based self-testing kit?
Note: Any “yes” response (other than for Q1) must be discussed with the dentist immediately.
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