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EMERGENCY CONTACT
NEW PATIENT
Services
Digital Dentistry
Dental Implants
Aesthetics
Comprehensive Care
Lectures & Workshops
Smile Consult
Digital Smile Design
Meet Our Doctors
Dr. Paresh Shah
Dr. Neil Wilson
Meet Our Team
Contact
(204) 837-4517
Book Appointment
Call Today:
(204) 837-4517
Book Appointment
Services
Digital Dentistry
Dental Implants
Aesthetics
Comprehensive Care
LECTURES & WORKSHOPS
Digital Smile Design
Smile Consult
Meet Our Doctors
Dr. Paresh Shah
Dr. Neil Wilson
Meet Our Team
Contact
Covid Prescreen Form
If you have any questions, please call our office at
204-837-4517
.
Name :
Date :
Patient Screening Questions - Covid-19
1.) Do you have any of the following symptoms:
Fever/chills
Shortness of Breath/Chest pain
Sore throat
Dry cough
Congestion
Drowsiness
Loss of consciousness/confusion
Yes
No
2.) Have you been in contact with someone known to have tested positive with COVID-19?
Yes
No
3.) Have you had any contact with laboratory samples known to contain COVID-19?
Yes
No
4.) Have you been in a large group setting in Manitoba in the last 14 days?
Yes
No
5.) Have you traveled outside of Manitoba in the last 14 days?
Yes
No
If so, were you in any large group settings?
Yes
No
6.) Are you or someone you live with a health care worker/first responder?
Yes
No
7.) Do you or someone you live with work in a correctional facility,shelter,personal care home?
Yes
No
8.) Has a member of your household been identified as a close-contact and instructed to self-isolate (quarantine) by public health officials,and they are not able to isolate from you?
Yes
No
Submit
