Patient Screening Form :: Arbutus Dental

250-752-7524

Patient Name *

Completed by

(if done by another family member)

Patient Age *

Preferred Contact Method *

Phone

Other

Please choose YES or NO for each of the following questions

Do you have any symptoms of: Dry cough? Shortness of breath? Difficulty breathing? Sore throat, fever, or any flu like Symptoms in the last 2 weeks?

Yes

Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19?

Yes

Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19?

Yes

Please choose YES or NO for each of the following questions

Have you had any changes to your health, or have you been hospitalized in the last year?

Yes

To the best of your knowledge are you considered in good health?

Yes