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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 ________________________

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

reception@langleydentist.com

HOURS:

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