4444 Drummond Rd.,

Niagara Falls, ON, L2E 6C6

Sleep Dentist for Kids/Adults

289-271-0021

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Covid-19 Pre-screen Questionnaire

Please fill in the following form and submit before you appointment.

Patient Name*
First Last
Birthdate*
MM slash DD slash YYYY
E-mail Address*
Covid-19 Prescreening Questions
Have you had close contact with anyone with acute respiratory illness or travelled outside of Ontario in the past 14 days?*
- Yes
- No
Have you tested positive for COVID-19 or had close contact with a confirmed case of COVID-19?*
- Yes
- No
Do you have any of the following symptoms?*
- I have none of these symptoms
- Fever
- New onset of cough
- Worsening chronic cough
- Shortness of breath
- Difficulty breathing
- Sore throat
- Difficulty swallowing
- Decrease or loss of sense of taste or smell
- Chills
- headaches
- Unexplained fatigue/malaise/muscle aches (myalgias)
- Nausea/vomiting, diarrhea, abdominal pain
- Pink eye (conjunctivitis)
- Runny nose/nasal congestion without other known cause
Signature*
Date of Application*
MM slash DD slash YYYY

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Contact Niagara Falls Dentist

289-271-0021

Dr.Andrew Tortorella
Niagara Dentist

4444 Drummond Rd.
Niagara Falls, ON, L2E 6C6

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About Us
- Meet the Staff
New Patient
Insurance
Book Appointment
Children
Services

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