Patient Screening Form

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Please complete this form before your appointment.

Email *

Appointment Date *

YYYY

Patient name *

Name of Person Completing Form *

Do you have a fever or have felt hot or feverish anytime in the last two weeks?? *

Yes

Do you have any of these symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose? *

Yes

Have you been in contact with any confirmed COVID-19 positive patients, or persons, self-isolating because of a determined risk for COVID-19? *

Yes

Have you been outside Canada in the past 2 weeks? *

Yes

Have you experienced a recent loss of smell or taste? *

Yes

Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder? *

Yes

When you arrive for your appointment:

Please wear a mask. If you don’t have a mask, one will be provided. Dr. Tawil does request only the person booked for the appointment come into the office. Minors may be accompanied by one adult.

1. Call us or knock on the door when you arrive to let us know you are here.
2. When Dr. Tawil or the hygienist is ready for you they will unlock the door and invite you into the office.
3. If you have not completed your COVID-19 screening online the day of your appointment you will be asked the screening
questions.
4. Your temperature will be taken.
5. There is hand sanitizer for your use.
6. You will then be taken into the operatory for your treatment.

Upon dismissal:

You will be given hand sanitizer when you are finished your treatment. Please come to the front desk to complete your appointment. When you have been dismissed, you will be escorted from the office. Thank you for your co-operation in these unprecedented times.

Good Health to All, Dr. Jawad Tawil and Team

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