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Dental implants
Wisdom teeth
Complex extractions
Intravenous sedation
Orthognathic surgery
Oral pathology
Traumatology
3D Radiology
Our clinic: who are we?
Team
Dr. Mathieu Lenis, DMD, FRCD(C)
Patients
Preoperative Instructions
Postoperative Instructions
Confidential Medical Questionnaire
COVID-19 Questionnaire
Professionals
Referral Form
Login « Intranet/ partnership zone »
Blog
Contact
Services
Dental implants
Wisdom teeth
Complex extractions
Intravenous sedation
Orthognathic surgery
Oral pathology
Traumatology
3D Radiology
Our clinic: who are we?
Team
Dr. Mathieu Lenis, DMD, FRCD(C)
Patients
Preoperative Instructions
Postoperative Instructions
Confidential Medical Questionnaire
COVID-19 Questionnaire
Professionals
Referral Form
Login « Intranet/ partnership zone »
Blog
Contact
Patient/Attendant Screening Questionnaire
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Date
Name of the person being screened
*
This form is fill :
*
At the appointment scheduling (Pre-Op)
Just before (the day of) my appointment
Please indicate if the name below corresponds to the patients questionnaire or the person accompanying the patient?
*
Patient
Attendant
If attendant name of patient
*
1- Have you had a positive COVID-19 screening test in the last 21 days or are you awaiting a screening test result?
*
Yes
No
Have you experienced any of the following symptoms
2- Fever (over 38 °C or 100,4 °F)?
*
Yes
No
3- Recent or chronic cough that has gotten worse?
*
Yes
No
4- Difficulty breathing (e.g. shortness of breath or difficulty speaking)?
*
Yes
No
5- Sudden loss of smell (with or without loss of taste)?
*
Yes
No
6- Muscle pain, headache, intense fatigue or severe loss of appetite?
*
Yes
No
7- Sore throat
*
Yes
No
8- Diarrhea
*
Yes
No
9- Have you been in close contact (at least 15 minutes within 2 meters) with a confirmed or probable case of COVID-19?
*
Yes
No
Signature of the person who filled out the questionnaire
*
Reset signature
Signature locked. Reset to sign again
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