RICHMOND ORTHODONTIC CENTRE
PLEASE COMPLETE THIS FORM ONE DAY BEFORE YOUR APPOINTMENT

As recommended by the College of Dental Surgeons of BC and the BC CDC, we are asking patients to review the following information and complete the questionnaire prior to their scheduled appointment. If you have any questions regarding this form, please call our office at 604-276-8225. Thank you for your understanding and cooperation!

If you have concerns or questions about your health, please contact HealthLinkBC (8-1-1) or speak with your health care provider.
Email *
Patient's First and Last Name *
Does the patient have any new cold or flu-like symptoms in the past month such as fever, chills, muscle aches, cough, sore throat, runny nose or loss of sense of smell? *
Has the patient been in contact with anyone who has tested positive for COVID-19 or suspected of having COVID-19 in the past month? *
Has the patient returned from travel outside of British Columbia in the last 14 days? *
Has the patient been in a setting in the last 14 days that has been identified by public health as a risk for acquiring COVID-19, such as on a flight, in a workplace with a cluster of cases, or at an event? *
COVID-19 PATIENT CONSENT FORM
I understand that due to the visits of other patients, the characteristics of COVID-19, and the characteristics of dental procedures, that the patient has an elevated risk of contracting and spreading COVID-19 by being in the dental office. *
I confirm that the patient does NOT have any symptoms of COVID-19: fever, new or worsening cough, sore throat, runny nose, headache, etc. *
I confirm that this is not currently a period where the patient is required to self-isolate for 14 days. *
I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic. *
Please type your full name below to electronically sign this document. Please type your name if you are a parent/guardian completing this form for a minor. *
PLEASE REVIEW THE NEW OFFICE PROTOCOL AND SCROLL TO THE BOTTOM TO SUBMIT THIS FORM
o We are asking for only the scheduled patient to come into the office and to have parents, guardians, siblings, and friends wait in the car or elsewhere. If the patient needs a parent/guardian to accompany them, we ask that only one parent/guardian come in the office with the patient.
o Please wear a mask to your appointment. If you do not have a mask, we can provide one.
o Please brush before you come for your appointment. The office brushing area has been closed.
o Please use the provided hand sanitizer upon entering the office.
o Once in the clinic, patients will be asked to rinse with a disinfectant mouth rinse.
o Please try to follow social distancing and keep your distance from other patients in the office.
o We are limiting the number of patients each day to minimize the number of people in the office at one time and to allow greater time between patients
o We would appreciate at least two days notice for any appointment changes, but if you are feeling unwell or have been exposed to someone with symptoms, please call our office and we would be happy to help reschedule you.
A copy of your responses will be emailed to the address you provided.
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