Patient COVID Pre-screening Form

Please fill out within 48 hours of receipt of our 1 week pre-screening reminder email.

    Patient Information





     


     

    Screening Questions

     

    1. Are you fully vaccinated?

    If YES, did you receive your final (or second- if applicable to your COVID-19 vaccine type) vaccination dose more than 14 days ago?

     

    2. Are you currently experiencing one or more of the symptoms below that are new or worsening? Symptoms should not be chronic or related to other known causes or conditions.

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

     

    3. Have you tested positive for COVID-19 in the past 10 days or have you been told you should be isolating?

     

    If you answered “NO” to QUESTION 1, please respond to QUESTION 4 and QUESTION 5.
    (I.e. ONLY ANSWER QUESTIONS 4 and 5 IF you are NOT FULLY IMMUNIZED.)

     

    4. Have you travelled outside of Canada in the past 14 days?

     

    5. Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?

     


     

    White Tooth Dental COVID Safety Protocols

    • EVERY PERSON (patient or otherwise) MUST be wearing a mask to enter and for the duration of their visit (except during treatment)
    • Please sanitize hands upon entering and departing at our sanitation station
    • Your temperature will be taken
    • Please do not bring a guest with you (special exceptions will be considered)
    • If you are early OR the waiting room is fully occupied when you arrive: please exit the building (please try not to linger in the hallway) and wait in your car until your appointment OR wait outside the building, and call the office when you arrive. We will call you back once the waiting room is clear and your room is ready for you.
    • If we don't have a MOBILE NUMBER for you, please provide it here, in case we have to call you back into the office

     

    Do you agree to comply with our in-office safety protocols?

     

    Emergency Appointments Available

    Call 416.766.7282

    Family Dentist White Tooth Dental IconDr. Kristina Pahuta (Moore), Dr. James Kiproff & Dr. Sherry Masen

    White Tooth Dental is a family dentist clinic serving the Toronto and Etobicoke area offering teeth cleanings, dental check ups, pediatric dentistry and invisalign.