Patient Screening Form

Please read this form and sign where indicated. Use this form to screen patients before their appointment and when they arrive for their appointment.

  • 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

Our Location

15252 32 Ave #101
Surrey, BC V3Z 0R7
Canada

(Opposite Surrey Fire Service Hall on 32nd Ave Diversion in South Surrey/ White Rock)

Our Hours

Mondays 9am – 8pm
Tuesdays – Fridays 9am – 5pm
First Saturday of Every Month 8am – 2pm

Call Us

NO INSURANCE? NO PROBLEM.
WE’LL HELP YOU FIND A PAYMENT PLAN THAT FITS YOUR BUDGET.

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