Blue Quill Dental Centre
COVID-19 Screening Form


COVID-19 Pandemic Dental Treatment Screening Form

  • CMOH Order 05-2020 legally obligates any person who has the following cough, fever, shortness of breath, runny nose, or sore throat (that is not related to a pre-existing illness or health condition) to be in isolation (quarantine) for 10 days from the start of symptoms, or until symptoms resolve, whichever takes longer. If they are exhibiting any of these symptoms, it is suggested they complete the COVID-19 Self-Assessment online tool to determine if they should be tested.

  • Please confirm the following:

    Please note: Any individual who has gone in for testing on their own volition as an asymptomatic individual does not need to indicate that.
  • This field is for validation purposes and should be left unchanged.