Appointment Day Form

We require this form to be completed on The Day of Your Next Appointment!

To ensure the health and safety of both our patients and staff during the COVID-19 pandemic, we require submission of consent in order for patients and staff to attend appointments.

All patients are required to review and submit a consent form prior to coming in for their next dental appointment.

IMPORTANT: When you click submit, you will receive a successful confirmation message. If you do not see the confirmation message, you will need to check through the form and complete any missing information. A confirmation e-mail will be sent to you confirming the successful submission to Dr. Neville Ananthan if an email is provided.

    *Date:

    *Patient Name:

    *Patient Age:

    *Who is completing this form?: PatientOther

    If Other:

    Cell Phone:

    Home Phone:

    *E-mail:

    PLEASE SELECT YES OR NO IN ANSWER TO EACH OF THE FOLLOWING QUESTIONS

    *Have you travelled outside Canada in the past 14 days?

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

    Do you have any of the following symptoms?

    • *Fever greater than 38°C?
    • *New oneset 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?

    *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, or worsening of chronic conditions? ANSWER NO IF YOU ARE UNDER 70 YEARS OF AGE

    SIGNATURE OF PATIENT

    *NOTE* Please wait till you have the success confirmation message.

    We look forward to seeing you at your next dental appointment!