PORT Pre-Screening | wavedental

Port Perry Covid-19 Health Declaration

How are you feeling today? Please complete this form no more than 48 BUSINESS hours before your scheduled appointment.

First Name

Last Name

I have not tested positive for COVID-19 in the past 10 days or have been told to self isolate

I do not have ANY of the following symptoms:

Fever and/or chills
New onset of cough / 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 (myalgia)
If child <18 years of age: nausea/vomiting, diarrhea

I have not travelled outside of Ontario in the last 14 days and/or I have been fully vaccinated for 14 days.

I have not had close contact with a confirmed case of Covid-19 without wearing appropriate PPE and/or I have been fully vaccinated for 14 days.

Initials

Date

If this form cannot be submitted, please call the office directly.

905-982-0399