Ajax: 905-239-3478
Bowmanville: 905-419-5232



I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. I understand that due to the frequency of visits of other denturist patients, the characteristics of the novel coronavirus, and the characteristics of denture procedures, that I have an elevated risk of contracting the novel coronavirus simply by being in a denturist office.

Covid Screening
Patient Name
I am fully vaccinated for Covid-19
I have a fever greater than 38°C / 100°F
I have a new cough
I have shortness of breath
I have flu-like symptom
I have tested positive for the novel coronavirus
I am currently waiting for the results of a laboratory test for the novel coronavirus.
I have been outside the country in the past 14 days.
I have diabetes
I have respiratory problems
I have an autoimmune disorder