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 a fever or have you felt hot/feverish anytime in the last 14 days (37.5°C or chills)?
Do you have a recent loss of smell or taste, feeling tired or fatigued without explanation, new or worsening headache or other cold or flu-like symptoms, Dry Cough, Shortness of Breath, Difficulty Breathing, Sore Throat, Runny Nose orPost-nasal Drip?
Is your workplace considered high risk? Do you socially distance and wear a mask at work?
In the past 14 days, have you returned from travel outside of Canada or from within Canada from a known COVID-19 affected area, travelled outside of BC, or attended a social gathering of more than six people?