+1-202-555-0175 contact@dentalhygieneofniagara.ca

Client Care

A safe and efficient way for patients to submit forms in advance and online.

Client Care

Covid-19 Screening Form

Please fill out this form to the best of your knowledge. If you have any questions while completing these forms, please don’t hesitate to contact us.

  • Patient Screening Form

Patient Screening Form

Please remember, if you are filling out this form on behalf of someone else, you are answering the questions as "they" not "you."

Patient Name

Patient Date of Birth

Are you/ they fully vaccinated against COVID-19? and/or aged 11 or younger? If you are immunocompromised, select “No.”

Are you/they having shortness of breath or other difficulties breathing?

Do you/they have a sore throat?

Do you/they have a cough?

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Are you/they in contact with any confirmed COVID-19 positive patients? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

Have you/they tested positive for COVID19 in the last five days?

Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Have you/they traveled in the past 14 days to any regions affected by COVID-19 (relevant to your location)?

Positive responses to any of these would likely indicate a deeper discussion with the dental hygienist before proceeding with elective dental hygiene treatment.

By checking this box, you agree that the information you have provided is true to the best of your knowledge.