DENTAL CARE PATIENT SCREENING FORM

Please fill out the form before you come to your appointment

Are you aware you are COVID-19 positive or are you waiting for a test result?
Do you have any of the following symptoms; hot/feverish, chills, recent loss of smell or taste, feeling tired or fatigued without explanation, new or worsening headache, cold or flu-like symptoms, runny nose or post-nasal drip?
Are you in public spaces or at work where you DON'T socially distance or wear a mask?
Is your workplace considered high risk?
In the past 14 days, have you returned from travel outside of BC, or attended a social gathering of more than six people?