Patient Screening Form

    Please fill out this mandatory screening form based on the new guidelines established by the NB Dental Society.

    1. Do you have TWO (2) of the following s symptoms that are not related to a known pre-existing condition: A fever anytime in the last two weeks? Cough? Sore throat? Runny nose? Diarrhea? Headache? Loss of smell/taste? Fatigue/exhaustion? Muscle pain? Children: Any purple markings on fingers/toes?
    YESNO
    2. Have you been advised by Public Health, a health care provider or a peace officer that you are currently
    required to self-isolate?
    YESNO
    3. Are you waiting for a Covid-19 test or Covid-19 test results AND have been told you need to self-isolate?
    YESNO
    4. Have you travelled outside of the province within the last 14 days? (unless exempt from self-isolation)?
    YESNO relevance to me
    5. Has an individual in your household returned from outside of the province in past 14 days for any reason, and now someone within the household has developed one or more symptoms of Covid-19 as listed above?
    YESNO
    6. Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any autoimmune disorder?