Buswell Dental Centre Appointment Questionnaire
Buswell Dental Centre
Dr. Tina He
Tel: 604-278-8243, 604-278-8246
Address: Unit 101-6480 Buswell Street, Richmond, BC
Email *
Name *
Do you have a fever or have felt hot or feverish anytime in the last two weeks? *
Temperature at appointment in Celsius *
Do you have any of these symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose? Sneezing?Post-nasal drip? *
Have you experienced a recent loss of smell or taste? *
Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19? *
Have you returned from travel outside of Canada in the last 14 days? *
Have you returned from travel within Canada from a location known affected with COVID-19? *
Is your workplace considered high risk? *
I understand that I will call office to discuss my appointment if I have a "Yes" response for one of the above questions. *
Required
Are you over the age of 70? *
Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder? *
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