The Clay Emporium
Patient Pre-Screening Form
271 Old Kingston Road, Toronto, ON M1C 1B4
Have you had close contact with anyone with acute respiratory illness or travelled outside of Ontario in the past 14 days?
Do you have a confirmed case of Covid19 or had close contact with a confirmed case of Covid-19?
Do you have any of the following symptoms?
New Onset of Cough
Worsening Chronic Cough
Shortness of Breath
Decrease or loss of sense of taste of smell
Unexplained fatigue/malaise/muscle aches (myalgias)
Nausea/vomiting, diarrhea, abdominal cramps (of unknown origin)
Pink eye (conjunctivitis)
Runny nose/nasal congestion without other known cause
I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have dental treatment completed today during the COVID-19 pandemic
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