8590 200 St Unit # 3

Langley City, BC V2Y 2B9

604-455-6247

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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 ________________________
  • Reset signature Signature locked. Reset to sign again
  • This field is for validation purposes and should be left unchanged.

Adapted from Dental Association of PEI COVID-19 Pandemic Emergency Dental Risk Acknowledge by Patient

ADDRESS:

8590 200 St Unit # 3,
Langley City, BC V2Y 2B9

PHONE:

604-455-6247

EMAIL

[email protected]

HOURS:

Monday: 9:30AM–5:30PM
Tuesday: 10AM–6PM
Wednesday: 9AM–5PM
Thursday: 9:30AM–5PM
Friday: Closed
Saturday: 8AM–3PM
Sunday: Closed

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Contact Us

8590 200 St Unit # 3
Langley City, BC V2Y 2B9

604-455-6247

[email protected]

Sunday: Closed
Monday: 9.30am – 5.30pm
Tuesday: 10am – 6pm
Wednesday: 9am – 5pm
Thursday: 9.30am – 5pm
Friday: Closed
Saturday: 8am – 3pm

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