(905) 281-8200265 Enfield Place, Suite 100B Mississauga25 King George Rd, Brantford, ON‎ 415 Fairview Dr, Brantford, ON

TROPICAL ORTHODONTICS

Braces | Orthodontic Specialists

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COVID-19 Same Day Screening

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COVID-19 Same Day Screening

If you have any questions about this form please email us at info@tropicalorthodontics.com
or call us at (905) 281-8200, we will be happy to help!

Name

First

Last

Date

Does patient have fever or have you/they felt hot or feverish recently (the last 14 days)?

Yes

No

Does the patient have shortness of breath or other difficulties breathing?

Yes

No

Does the patient currently have a cough?

Yes

No

Does the patient have any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Yes

No

Has the patient experienced recent loss of taste or smell?

Yes

No

Has the patient experienced recent loss of taste or smell?

Yes

No

Has the patient been in contact with any confirmed COVID-19 positive patients? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

Yes

No

This field should be left blank

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mail: info@tropicalorthodontics.comTel: (905) 281-8200

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