Patient Screening Form

Please complete and return a copy of this form to the dental office at least 48 hours in advance of your scheduled appointment.

  • Date Format: MM slash DD slash YYYY
  • Please note that no data transmission over the internet can be guaranteed to be 100% secure. As a result, we cannot guarantee the security of any information you transmit to us over the internet, and you do so at your own risk If you would prefer to contact us by telephone to complete this screening questionnaire, please call: 604-670-5301