New Patient Package: Patient Screening Form

    Patient Screening Form


    Who answered:
    If Other, Specify the name:

    How to Contact:

    Screening Questions


    1. Are you currently waiting for the results of a COVID-19 test?
    Pre-Screen

    2. Do you have any of these symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose? Sneezing? Post-nasal drip?
    Pre-Screen

    3. Have you experienced a recent loss of smell or taste?
    Pre-Screen

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

    5. Have you returned from travel outside of Canada in the last 14 days?
    Pre-Screen

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

    7. Is your workplace considered high risk?
    Pre-Screen

    Patient Vulnerability


    8. Are you over the age of 70?
    Pre-Screen

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

    .

    Draw Your Signature
    By entering your full name, email address, and phone number, you agree with online transfer of information that will be used by Vancouver Dental Specialty Clinic for the sole purpose of returning your request to be contacted by us. Vancouver Dental Specialty Clinic takes no responsibility for web communication.
    By entering your full name, email address, and phone number, you agree with online transfer of information that will be used by Vancouver Dental Specialty Clinic for the sole purpose of returning your request to be contacted by us. Vancouver Dental Specialty Clinic takes no responsibility for web communication.

    3488 West Broadway

    Vancouver, BC, V6R 2B3

    604-336-0958

    Call us!