Patient Screening FormFirst NameMiddleLast NamePreferred NameWho answered:(Required) Patient OtherIf Other, Specify the name:How to Contact:(Required) Phone EmailPhone(Required)Email(Required) Screening Questions1. Are you currently waiting for the results of a COVID-19 test?Pre-Screen(Required) Yes No2. 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 No3. Have you experienced a recent loss of smell or taste?Pre-Screen(Required) Yes No4. 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 No5. Have you returned from travel outside of Canada in the last 14 days?Pre-Screen(Required) Yes No6. Have you returned from travel within Canada from a location known affected with COVID-19?Pre-Screen(Required) Yes No7. Is your workplace considered high risk?Pre-Screen(Required) Yes NoPatient Vulnerability8. Are you over the age of 70?Pre-Screen(Required) Yes No9. Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?Pre-Screen(Required) Yes NoConfirmation_checkbox(Required) I CONFIRM THAT THE INFORMATION GIVEN IN THIS FORM IS TRUE, COMPLETE AND ACCURATE.Draw Your Signature(Required)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.