Walk In Family Dental
Menu
Home
About Us
Services
General Dentistry
Endodontics: Rescuing Smiles, One Root at a Time”
Tooth Extraction North York
Dental Crowns North York
Dental Filling in North York
Dental bridges North York
Wisdom Tooth Extraction North York
Dental Care for Refugees in North York
Same-day Appointments in North York
Cosmetic Dentist North York
Dental Implants North York
Invisalign North York
Teeth Whitening North York
Dental Veneers North York
Dental Bonding
Orthodontist North York
Dentures North York
Emergency Dentist North York
Patient Forms
Consent forms
information update form
New patient forms
Consent of Extraction Form
Patient Acknowledgement
Patient Screening Form
Consent for Dental Crown Form
Consent for Bridge Prosthetics
Gingival Grafting Surgery Consent Form
Dental Implant Consent Form
Consent for Maxillary Sinus Elevation Surgery
Information & Consent for Root Canal Therapy
Financial Agreement
CONSENT FORM FOR BONE GRAFTING SURGERY
Consent for Scaling & Root Planing
Braces Removal and Retainer Consent Form
Consent for Composite or Porcelain Veneers Form
Consent For Full Dentures And Partial Dentures Form
CONSENT FORM FOR CROWN LENGTHENING SURGERY
CONSENT FORM FOR OCCLUSAL GUARD
CROWN AND BRIDGE CONSENT FORM
Informed Consent And Agreement For The Invisalign Patient
voluntary and Informed Consent for Final Cementation
Post op instructions
Braces Post Op Instruction
Blog
Contact Us
Call: +1 (647) 799-6622
Appointment
Our Location
Home
About Us
Services
General Dentistry
Endodontics: Rescuing Smiles, One Root at a Time”
Tooth Extraction North York
Dental Crowns North York
Dental Filling in North York
Dental bridges North York
Wisdom Tooth Extraction North York
Dental Care for Refugees in North York
Same-day Appointments in North York
Cosmetic Dentist North York
Dental Implants North York
Invisalign North York
Teeth Whitening North York
Dental Veneers North York
Dental Bonding
Orthodontist North York
Dentures North York
Emergency Dentist North York
Patient Forms
Consent forms
information update form
New patient forms
Consent of Extraction Form
Patient Acknowledgement
Patient Screening Form
Consent for Dental Crown Form
Consent for Bridge Prosthetics
Gingival Grafting Surgery Consent Form
Dental Implant Consent Form
Consent for Maxillary Sinus Elevation Surgery
Information & Consent for Root Canal Therapy
Financial Agreement
CONSENT FORM FOR BONE GRAFTING SURGERY
Consent for Scaling & Root Planing
Braces Removal and Retainer Consent Form
Consent for Composite or Porcelain Veneers Form
Consent For Full Dentures And Partial Dentures Form
CONSENT FORM FOR CROWN LENGTHENING SURGERY
CONSENT FORM FOR OCCLUSAL GUARD
CROWN AND BRIDGE CONSENT FORM
Informed Consent And Agreement For The Invisalign Patient
voluntary and Informed Consent for Final Cementation
Post op instructions
Braces Post Op Instruction
Blog
Contact Us
Book an Appoinment
+1 (647) 799-6622
2365 Finch Ave W #201, Toronto, ON M9M 2W8
Patient Screening Form
Step
1
of
2
50%
Use this form to screen patients before their appointment and when they arrive for their appointment.
Staff screener:
Patient Name:
*
Patient age:
*
Phone
*
Email
*
Who answered:
Patient
Other (specify)
specify
Contact Method:
Phone
Email
Other
Do you have a fever or have felt hot or feverish anytime in the last two weeks? (P-S)
*
Yes
No
Pre-Screen *
Patient's temperature at appointment:
Do you have any of these symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose? (P-S)
*
Yes
No
Pre-Screen *
Have you experienced a recent loss of smell or taste? (P-S)
*
Yes
No
Pre-Screen *
Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19? (P-S)
*
Yes
No
Pre-Screen *
Have you returned from travel outside of Canada in the last 14 days? (P-S)
*
Yes
No
Pre-Screen *
Have you returned from travel within Canada from a location known affected with COVID-19? (P-S)
*
Yes
No
Pre-Screen *
Are you over the age of 60? (P-S)
*
Yes
No
Pre-Screen *
Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder? (P-S)
*
Yes
No
Pre-Screen *
Any “yes” response must be discussed with the managing dentist immediately.
Please read the patient acknowledgement below, and initial or sign in all areas indicated.
I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. I understand the novel coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. For this reason, it is recommended to stay home and avoid close contact with other people when at all possible.
*
* Initial
I understand the federal and provincial governments have asked individuals to maintain social distancing of a least 2 metres (6 feet) and I recognize it is not possible to maintain this distance while receiving dental treatment.
*
* Initial
I understand that oral surgery/dental procedures can create water and/or blood spray, which is one important way that the novel coronavirus can spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the novel coronavirus.
*
* Initial
I understand that due to the visits of other patients, the characteristics of the novel coronavirus, and the characteristics of dental procedures, that I have an elevated risk of contracting AND SPREADING the novel coronavirus simply by being in the dental office.
*
* Initial
I confirm that I do NOT have any TWO OR MORE or the following symptoms of COVID-19: fever, new or worsening cough, sore throat, runny nose or headache.
*
* Initial
I confirm that I have not tested positive for COVID-19.
*
* Initial
I confirm that I am not waiting for the results of a test for COVID-19.
*
* Initial
I confirm that this is not currently a period where I required to self-isolate for 14 days.
*
* Initial
Please verify your provided information
*
I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have emergency surgical/dental treatment completed during the COVID-19 pandemic. (SIGNATURE OF PATIENT and Date)
1500$ Off Orthodontist
Fill out the form to take advantage of the promotions!