Patient Screening Form

Please read this form and sign where indicated.

  • Screening Questions

    In-office Screening: Initials ________________________
  • In-office Screening: Initials ________________________
    In-office Screening: Initials ________________________
    In-office Screening: Initials ________________________
    In-office Screening: Initials ________________________
    In-office Screening: Initials ________________________
    In-office Screening: Initials ________________________
  • Patient Vulnerability:

    In-office Screening: Initials ________________________
    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

    In-office Screening: Initials ________________________
    In-office Screening: Initials ________________________
    In-office Screening: Initials ________________________
    In-office Screening: Initials ________________________
    In-office Screening: Initials ________________________
    In-office Screening: Initials ________________________
    In-office Screening: Initials ________________________

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