COVID 19 Screening Form

Health care that cares! We understand the current pandemic situation, and so we take utmost care of our patient’s health.

Your safety is our primary concern!

The re-opening of all the essential services at Tooth Buds Dentistry after the pandemic is now in full effect, and we are fully functional with all the safety concerns.

Fill out the COVID-19 screening questionnaire before scheduling an appointment to endow us with complete insight into your current medical health.

Connect now to get the consultations!

Are you a current or new patient?

Medical History

Please check off each question of the screening questionnaire with yes or no and answer where applicable.

Do you have a fever or have shakes or chills?

New or worsening cough?

Shortness of breath?

Sore throat or hoarse voice?

Runny nose, sneezing or nasal congestion?

Fatigue, muscle or joint pain?

Nausea, vomitting or diarrhea

Difficulty swallowing?

Decreased or lost sense of taste or smell?


Abdominal Pain?

Pink eye ( conjunctivitis ) ?

Have you travelled outside of Canada in the last 14 days? Or been in close contact with someone else?

Have you been tested for COVID-19

Do you have any of the above symptoms?


For patient 65 years or older, are you experiencing any of the following symptoms: unexplained or increased number of falls, acute functional decline or worsening of chronic conditions.

lf response to all screening questions is checked non of the above, COVID screen negative.

lf response to any screen questions is questions is checked, COVID screen positive.

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