Patient Screening Form

Please read this form and sign where indicated.

Staff Screener: (A member of the office staff will complete "Staff Screener")
First Last
Patient Name*
First Last
Patient Age*
Email*
Phone*
Screening Questions
Do you have a fever or have felt hot or feverish anytime in the last two weeks?*
- Yes
- No
In-office Screening: Initials ________________________
Patient temperature at appointment: (Patient Temperature to be taken by Staff at the office if patient answered yes to the question about fever.)
In-office Screening: Initials ________________________
Do you have any of these symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose? Sneezing? Post-nasal drip?*
- Yes
- No
In-office Screening: Initials ________________________
Have you experienced a recent loss of smell or taste?*
- Yes
- No
In-office Screening: Initials ________________________
Have you returned from travel outside of Canada in the last 14 days?*
- Yes
- No
In-office Screening: Initials ________________________
Have you returned from travel within Canada from a location known affected with COVID-19?*
- Yes
- No
In-office Screening: Initials ________________________
Is your workplace considered high risk?*
- Yes
- No
In-office Screening: Initials ________________________
Patient Vulnerability:
Are you over the age of 70?*
- Yes
- No
In-office Screening: Initials ________________________
Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?*
- Yes
- No
In-office Screening: Initials ________________________
Any “yes” response for questions 1-7 must be discussed with the managing dentist immediately.

Tell the patient when they arrive at the office, they will be asked to: sanitize their hands; answer the questions again; have their temperature taken; complete a form acknowledging the risk of COVID-19.
Advise the patient:

Only patients are allowed to come to the office.

If possible to wait in their car until their appointment, call the office when they arrive.
Additional Screening Questions
Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19?*
- Yes
- No
In-office Screening: Initials ________________________
I understand there is currently a health pandemic associated with COVID-19 and the novel coronavirus.*
- Yes
- No
In-office Screening: Initials ________________________
I understand public health authorities have recommended maintaining social distancing of a least 2 metres (6 feet) and it is not possible to maintain this distance while receiving dental treatment.*
- Yes
- No
In-office Screening: Initials ________________________
I understand that oral surgery/dental procedures can create water and/or blood spray, and that there may be an elevated risk of contracting and spreading the novel coronavirus in a dental office.*
- Yes
- No
In-office Screening: Initials ________________________
I confirm that I do not have any two or more of the following symptoms of COVID-19: fever, new or worsening cough, sore throat, runny nose or headache, and that this is not currently a period where I am required to self-isolate for 14 days.*
- Yes
- No
In-office Screening: Initials ________________________
I confirm that I have not tested positive for COVID-19 and that I am not currently waiting for the results of a test for COVID-19.*
- Yes
- No
In-office Screening: Initials ________________________
I hereby consent to have dental treatment completed during the COVID-19 pandemic.*
- Yes
- No
In-office Screening: Initials ________________________
SIGNATURE OF PATIENT*
Date*

Adapted from Dental Association of PEI COVID-19 Pandemic Emergency Dental Risk Acknowledge by Patient.

Cambie Broadway Dental

507 W Broadway #360,

Vancouver, BC V5Z 1E6, Canada

604-877-1878

Hours of Operation

Monday: 10 AM–6 PM
Tuesday: 11 AM–7 PM
Wednesday: 9 AM–6 PM
Thursday: 8 AM–4 PM
Friday: 8 AM–4 PM
Saturday: 9 AM–4 PM
Sunday: Closed

Patient Screening Form

Screening Questions

Patient Vulnerability:

Any “yes” response for questions 1-7 must be discussed with the managing dentist immediately.

Advise the patient:

Additional Screening Questions

Cambie Broadway Dental

Hours of Operation