15252 32 Ave #101

South Surrey, BC V3Z 0R7 Canada

604-542-0123

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You and your family might be eligible for the new government dental plan, call us or fill the form to find out

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You and your family might be eligible for the new government dental plan, call us or fill the form to find out

Patient Screening Form

  • 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 ________________________
  • This field is for validation purposes and should be left unchanged.

NO RISKS, NO HIDDEN FEES.

We will provide a clear, detailed estimate on the cost of your treatment plan in writing so you know what to expect.

Let’s work together to give you a healthy mouth. Let’s start today.

New Government dental plan

  • This field is for validation purposes and should be left unchanged.