Patient Screening Form First Name Middle Last Name Preferred Name Who answered:(Required) Patient Other If Other, Specify the name: How to Contact:(Required) Phone Email Phone(Required)Email(Required) Screening Questions1. Are you currently waiting for the results of a COVID-19 test?Pre-Screen(Required) Yes No 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(Required) Yes No 3. Have you experienced a recent loss of smell or taste?Pre-Screen(Required) Yes No 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(Required) Yes No 5. Have you returned from travel outside of Canada in the last 14 days?Pre-Screen(Required) Yes No 6. Have you returned from travel within Canada from a location known affected with COVID-19?Pre-Screen(Required) Yes No 7. Is your workplace considered high risk?Pre-Screen(Required) Yes No Patient Vulnerability8. Are you over the age of 70?Pre-Screen(Required) Yes No 9. Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?Pre-Screen(Required) Yes No Confirmation_checkbox(Required) I CONFIRM THAT THE INFORMATION GIVEN IN THIS FORM IS TRUE, COMPLETE AND ACCURATE. Draw Your Signature(Required) Reset signature Signature locked. Reset to sign again 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.
