COVID-19 Screening Form

I confirm that I am not currently positive for the novel coronavirus.I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus.I confirm that I or anyone that I live with, have not come in contact with anyone who is currently being tested for COVID-19, or has tested positive for COVID-19 within the past 14 daysI verify that I have not returned to Provincial from any country outside of Canada whether by car, air, bus or train in the past 14 days.I understand that any travel from any country outside of Canada, including travel by car, air, bus or train, significantly increases my risk of contracting and transmitting the novel coronavirus. Provincial Health Services require self-isolation for 14 days from the date a person has returned to Canada.I confirm that I have not travelled anywhere outside of the province within the last 14 days.I confirm that I myself nor any family members that I live with have not been asked to self isolate or self quarantine for 14 days.I understand that Provincial Health Services has asked individuals to maintain social distancing of at least 2 metres (6 feet) and it is not possible to maintain this distance and receive dental treatment.I verify that I have not been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self-isolate by Provincial Health, the Communicable Disease Control or any other governmental health agency.I verify the information I have provided on this form is truthful and accurate.