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188 King St. S., Suite "C" Waterloo Ontario N2J 0C6
Phone:
(519) 888-6063
Email:
info@waterloosmiles.com
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Home
About Us
Our Team
Our Practice
Take a look inside
FAQs
Latest News
Policies
Our Services
Photo Gallery
Blog
Contact Us
Covid Prescreening
Home
Covid Prescreening
Patient Screening Form
Patient Name:
Email Address:
Have you received your final (or second) vaccination dose more than 14 days ago?
Yes
No
Do you have any of the following symptoms?
Fever and/or chills
New onset of cough or worsening chronic cough
Shortness of breath
Decrease or loss of sense of taste or smell
If adult >18 years of age: unexplained fatigue/lethargy/malaise/ muscle aches
(myalgias)
If child < 18 years of age: nausea/vomiting, diarrhea
Yes
No
Have you tested positive for COVID-19 in the past 10 days or have you been told you should be isolating?
Yes
No
Did you travel outside of Canada in the past 14 days?
Yes
No
Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?
Yes
No
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