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Patient Screening Form

All patients are to be screened before their appointment AND when they arrive for their appointment.

Patient Screening Form

    Screener Information

    (Please Leave Blank For Clinic Staff to Complete)

    Patient Information

    Who Answered?

    A dental team member will contact you and identify themselves and will then explain the purpose of the call before your appointment. The reason for this will be to determine whether there are any special considerations for your dental appointment. Please answer the following questions.

    Contact Method

    Screening Questions

    Do you have a fever or have felt hot or feverish anytime in the last two weeks?

    Before Appointment *

    In Clinic (Please Leave Blank for Clinic Staff to Complete)

    Patient temperature at appointment. If elevated, provide mask to patient.

    Do you have any of these symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose?

    Before Appointment *

    In Clinic (Please Leave Blank for Clinic Staff to Complete)

    Have you experienced a recent loss of smell or taste?

    Before Appointment *

    In Clinic (Please Leave Blank for Clinic Staff to Complete)

    Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19?

    Before Appointment *

    In Clinic (Please Leave Blank for Clinic Staff to Complete)

    Have you returned from travel outside of Canada in the last 14 days?

    Before Appointment *

    In Clinic (Please Leave Blank for Clinic Staff to Complete)

    Have you returned from travel within Canada from a location known affected with COVID-19?

    Before Appointment *

    In Clinic (Please Leave Blank for Clinic Staff to Complete)

    Are you over the age of 60 and have any underlying health conditions?

    Before Appointment *

    In Clinic (Please Leave Blank for Clinic Staff to Complete)

    Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?

    Before Appointment *

    In Clinic (Please Leave Blank for Clinic Staff to Complete)




    Any "Yes" response must be discussed with the managing dentist immediately.

    When you arrive at the office, you will be asked to:

    • Sanitize your hands.
    • Answer the questions again.
    • Have your temperature taken.
    • Complete a form acknowledging the risk of COVID-19.

    Please be advised:

    Only patients are allowed to come to the office. If possible, please wait in your car until your appointment, and call the office when you arrive to let us know you are waiting nearby.

    Business Hours

       

      • Monday: Closed
      • Tuesday: 9:30am – 7:00pm
      • Wednesday: 9:30am – 7:00pm
      • Thursday: 10:00am – 5:00pm
      • Friday: 8:30am – 6:00pm
      • Saturday: 8:30am – 2:30pm
      • Sunday: Closed

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