(778) 755-2577
|
[email protected]
|
Unit 208-525 HWY 97 South, West Kelowna, BC
OUR PRACTICE
ABOUT US
OUR TEAM
OUR OFFICE TEAM
OUR DR TEAM
OUR SERVICES
OUR SERVICES
Emergency Dentistry
FAQ
PATIENT FORMS
Medical and Dental History Form
Your Insurance Form
COVID-19 Consent Form
COVID-19 Prescreen Form
WHAT’S NEW
CAREERS
CONTACT
For Referring Doctors
Sedation Referral Form
OUR PRACTICE
ABOUT US
OUR TEAM
OUR OFFICE TEAM
OUR DR TEAM
OUR SERVICES
OUR SERVICES
Emergency Dentistry
FAQ
PATIENT FORMS
Medical and Dental History Form
Your Insurance Form
COVID-19 Consent Form
COVID-19 Prescreen Form
WHAT’S NEW
CAREERS
CONTACT
For Referring Doctors
Sedation Referral Form
Patient Name
*
First
Last
Do you have a fever or have felt hot or feverish anytime in the last two weeks?
*
Yes
No
Do you have any of these symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose? Sneezing? Post-nasal drip?
*
Yes
No
Have you experienced a recent loss of smell or taste?
*
Yes
No
Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk of COVID-19?
*
Yes
No
Have you returned from travel outisde of Canada in the last 14 days?
*
Yes
No
Have you returned from travel within Canada from a location known affected with COVID-19?
*
Yes
No
Is your workplace considered high risk?
*
Yes
No
Are you over the age of 70?
*
Yes
No
Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorder?
*
Yes
No
