Covid Screening Form | Apex Dental

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Covid-19 Health Declaration

Please fill this form online or over the phone prior to your appointment

First Name

Last Name

Phone

Email (optional)

My body temperature is lower than 98.6°F/ 37.5°C , I am not experiencing the symptoms: fever, new or worsening cough, sore throat, loss of smell, runny nose or headache. I haven't be in close contact with a Covid-19 patient in the last 14 days.

I confirm that I have not tested positive for COVID-19 and that I am not currently waiting for the results of a test for COVID-19.

I understand there is currently a health pandemic associated with COVID-19 and the novel coronavirus. I understant public health authorities have recommended maintaining social distancing of at least 2 meters (6 feet) and that it is not possible to maintain this distance while receiving dental treatment. I understand that oral surgery/dental procedures can create water and/or blood spray, and that there may be an elevated risk of contracting and spreading the novel coronavirus in a dental office. I hereby consent to have dental treatment completed during the COVID-19 pandemic.

Initials

Date

I declare that the info I’ve provided is accurate & complete

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Apex Dental Fort St John

The Dental office of Dr. Leslie Ho and Dr. Alex Man

Emergencies and New Patients Welcome.

Covid-19 Health Declaration