COVID-19 Screening Form
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 contact our office. 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.
Patient's Full Name *
Do you have any cold or flu-like symptoms such as fever, chills, muscle aches, cough, sore throat, runny nose or loss of sense of smell? *
Have you been in contact with anyone who has tested positive for COVID-19 or suspected of having COVID-19? *
Have you returned from travel outside of British Columbia in the last 14 days? *
Have you 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 I have an elevated risk of contracting and spreading COVID-19 by being in the dental office. *
I confirm that I do 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 I am 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 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. Please have family and friends wait elsewhere.
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.
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 If you are feeling unwell or have been exposed to someone with symptoms, please let us know and we would be happy to reschedule you.
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