RETURN TO WORK SCREENING FORM

Each employee/dentist at the office must complete this form upon return to work.

Name:

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Signature:

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Date:

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Risk Assessment Screening Questions

Do you have any of the following symptoms which are new or worsened if associated with allergies, chronic or pre­existing conditions: fever, cough, shortness of breath, difficulty breathing, sore throat, and/or runny nose?

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Have you returned to Canada from outside the country (including USA) in the past 14 days?

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In the past 14 days, at work or elsewhere, while not wearing appropriate personal protective equipment:

Did you have close contact* with someone who has a probable** or confirmed case of COVID­19?

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Did you have close contact* with a person who had acute respiratory illness who returned from travel outside of Canada in the 14 days before they became sick?

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Did you have close contact* with a person who had acute respiratory illness that started within 14 days of their close contact* to someone with a probable** or confirmed case of COVID­19?

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Did you have a laboratory exposure to biological material (i.e. primary clinical specimens, virus culture isolates) known to contain COVID­19?

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If you answer “NO” to all of the above, you can proceed to work. If you develop symptoms, please complete a new questionnaire.

If you answer “YES” to any of the above, you are not permitted to attend work at this time and you must self­isolate and contact a medical office to determine if you require COVID­19 testing.

*Close contact includes providing care, living with or otherwise having close prolonged contact (within 2 meters) while the person was ill, or contact with infectious bodily fluids (e.g. from a cough or sneeze) while not wearing recommended personal protective equipment.

**Probable case is a person with clinical illness who had close contact to a lab­confirmed COVID­19 case, while not wearing appropriate personal protective equipment, OR a person with clinical illness who meets the COVID­19 exposure criteria, AND in whom laboratory diagnosis of COVID­19 is inconclusive. Clinical illness of a probable case is new onset/exacerbation of following symptoms: fever (over 38 degrees Celsius), cough, shortness of breath (SOB)/difficulty breathing, sore throat or runny nose. Exposure criteria for a probable case is a person who, in the 14 days before onset of illness: had any history of travel outside of Canada; OR had close contact with a confirmed or probable case of COVID­19; OR is a close contact of a traveler with acute respiratory illness who returned from outside Canada in the previous 14 days; OR had a laboratory exposure to biological material (e.g. primary clinical specimens, virus culture isolates) known to contain COVID­19.

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  • Preferred time slot
  • 9 a.m - 10 a.m
  • 10 a.m - 11 a.m
  • 11 a.m - 12 p.m
  • 12 p.m - 1 p.m
  • 1 p.m - 2 p.m
  • 2 p.m - 3 p.m
  • 3 p.m - 4 p.m
  • 4 p.m - 5 p.m
  • 5 p.m - 6 p.m
  • 6 p.m - 7 p.m
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  • Preferred day
  • Monday
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Patient Reviews

Awesome company
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Carina Barros

Awesome company and super friendly staff!

Very good team!
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Breanna Thorn

I went to Stroud dental on monday for the first time in 13 years..... I was so afraid to go. The experience was amazing. They made me feel comfortable. Jess is very good at her job and gentle. I didnt feel embarrassed or shamed at all. They made sure I got my x Ray's up to date and informed me, my old x Ray's had baby teeth in them. Very good team! Happy I went in and faced my fears.

We highly recommend Stroud Dental!
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Shawna Toole

My husband is terrified of going to the dentist and after convincing him to go to Stroud Dental for the first time he has now been 3 times! The staff is absolutely amazing and made him feel safe and comfortable! He actually looks forward to going to the dentist now. Dr. Peleg rocks and the girls are a hoot. We highly recommend Stroud Dental!

The best experience I have ever had!
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Cassandra Dickson

Stroud dental was the best experience I have ever had! The staff are very knowledgeable and friendly, it was very clean, fast and efficient. thank you for making my smile beautiful! I would highly recommend this dental office.

A wonderful place to bring your children.
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Logan Beau

Stroud Dental is a wonderful place to bring your children. The staff are amazing with my sons, one of which is on the autism spectrum. They are patient and understanding of his quirks. If you’re looking for a great place for dental work check out Stroud Dental.

We couldn’t be more happy.
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Keith Shay Smeets

We have been patients of Stroud Dental for over five years!
They have the most amazing team, who make you feel comfortable, welcomed and part of their family!
They are so patient with our 15 month old daughter, and us!
We couldn’t be more happy with everyone at Stroud Dental!

Family, friendly!
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Dana Donaldson

Family, friendly! Have always been great with my kids. Always a pleasant experience.

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