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1. Have you travelled anywhere outside Canada in the last 14 days? YesNo
2. Have you been in contact with anyone that has tested positive for COVID-19? YesNo
3. Have you attended any large group functions? YesNo
4. Have you had any of the following symptoms within the last two weeks:
Fever or ChillsFatigueDry coughAltered Taste or SmellBreathingProductive cough (mucous in cough)Muscle PainNauseaHeadacheVomitingNONE OF THE ABOVE
5. Are you over the age of 65 and/or have pre-existing health conditions related to the following?
DiabetesChronic lung disease or asthmaHearth ConditionsImmunocompromisedChronic kidney or liver diseaseNONE OF THE ABOVE
I, the undersigned, understand that the information provided has been completed truthfully and to the
best of my knowledge and that I have not knowingly omitted data. I consent to the release of medical
information from my medical doctor or other health care provider as is required by this dental office.
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