Patient Screening Form

Please complete and submit this form to the dental office at least 48 hours in advance of your scheduled appointment.

Patient's legal name (REQUIRED)

Date of next appointment

Please answer completely:	Yes	No
1. Do you or anyone in your household have any of these: Fever? Cough? Sore throat or painful swallowing? Shortness of breath? Runny nose or sneezing? Loss of appetite? Chills? Muscle aches? Headache? Fatigue? Loss of smell or taste?
2. Have you had close contact with anyone diagnosed with lab-confirmed or suspected COVID-19?
3. Have you been advised to self-isolate or quarantine at home by Public Health?
4. Have you provided your name at the top of this screening form?

Please note that no data transmission over the internet can be guaranteed to be 100% secure. As a result, we cannot guarantee the security of any information you transmit to us over the internet, and you do so at your own risk. If you would prefer to contact us by telephone to complete this screening questionnaire, please call: 604-224-8000

Kitsilano dentist Last Updated: 27 April 2023