UX Pre-Screening | wavedental

Uxbridge 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

Check the box if the answer is NO

In the last 14 days have you been directed by a border agent to comply with federal quarantine requirements due to international travel?

In the last 5 days (if fully vaccinated) / 10 days (if vaccinated or immunocompromised) have you experienced any of these symptoms?

Fever and/or chills
Cough or barking cough
Shortness of breath
Decrease or loss of sense of taste or smell
Muscle aches or joint pain
Extreme tiredness
Sore throat
Runny or stuffy/congested nose
Headache
Nausea, vomiting and/or diarrhea

Do any of the following apply?

You live with someone who is currently isolating because of a positive COVID-19 test
You live with someone who is currently isolating because of COVID-19 symptoms
You live with someone who is isolating while waiting for COVID-19 test results

In the last 5 days (if fully vaccinated / 10 days (if vaccinated or immunocompromised) have you tested positive on a rapid antigen test, molecular test, or home-based self-testing kit?

Has a doctor, health care provider or public health unit told you that you should currently be isolating (staying at home)?

Initials

Date

Uxbridge Covid-19 Health Declaration

If this form will not submit, please contact the office directly.

905-862-2228

Wave Dental Port Perry

Wave Dental Uxbridge