COVID Screening - Sundridge Dental

Have you tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?

Yes No

Do you have any of the following symptoms?*

If you are 70 years of age or older, are you experiencing any of the following symptoms?

Delirium Unexplained or increased number of falls Acute functional decline Worsening of chronic conditions

Consent for Collection, Use and Disclosure of Personal Information

Consent for Collection
I agree that Sundridge Dental has obtained informed consent from me with respect to the collection, use and disclosure of my personal health information. I have been provided with a copy of the consent form and agree that personal information may be collected, used and disclosed as set out in the Privacy Policy for this office and is in accordance with the Personal Health Information Protection Act, 2004.