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 a fever or have felt hot or feverish anytime in the last two weeks?
YESNO
2. Do you have any of these symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose?
YESNO
3. Have you experienced a recent loss of smell or taste?
YESNO
4. Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19?
YESNO
5. Have you returned from travel within Canada from a location known affected with COVID-19?
YESNO
6. Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?
YESNO