Burlingwood Full Patient Form

Please correct the errors described below.

Patient Information

e.g. 123-456-7891
e.g. 123-456-7891


Medical History

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. Your data is stored in compliance with the PIPEDA (Personal Information Protection and Electronic Documents Act) of Canada.

Please fill in the following as best as you can:

Dental History

Your Smile

Covid-19 Patient Screening

  • Fever
  • New onset of cough
  • Worsening chronic cough
  • Shortness of breath
  • Difficulty breathing
  • Sore throat
  • Difficult swallowing
  • Decrease of 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

Only patients should attend the office if possible. If possible, please wait in car until your appointment, call the office at (905)332-6950 when you arrive. If you develop any of the above symptoms within 14 days, please give us a call.

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