COVID-19 Patient Screening

Please answer the following questions to ensure you are COVID-19 symptom free.

Patient Name *

Date *

It is important to closely monitor your health and the health of those you care for to help prevent the spread of COVID-19 and other illnesses like the flu.

1. Do You Feel Sick? *

Yes

2. In the past 48 hours, have you had, or are you currently experiencing;

Cough (New or Worsening) *

Yes

OR two or more of the following symptoms (new or worsening);

Fever (i.e. chills/sweats) *

Yes

Sore Throat *

Yes

Runny nose/nasal congestion *

Yes

Headache *

Yes

If yes, go home or stay home as noted above. Follow Public Health instructions for testing and isolation.

3. Have you recently visited a COVID-19 exposure site? *

Yes

4. Have you travelled in the past 14 days outside of the province and/or country AND been advised to self-isolate? *

Yes

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Welcoming Calgary's Young Smiles.

We are your children's pediatric dental specialists in Southwest Calgary.

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Kids R Us Dentistry

10201 Southport Rd SW #101 Calgary AB T2W 4X9 CA

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