PATIENT SCREENING FORM

Use this form to screen patients before their appointment and when they arrive for their appointment.

Staff Screener:

Field is required!

Patient Name:

Field is required!

Patient Age:

Field is required!

Who answered:

Field is required!
Field is required!

Contact Method:

Field is required!
Field is required!
Field is required!
Field is required!

Identify yourself and explain the purpose of the call, which is to determine whether there are any special considerations for their dental appointment. Have the patient answer the following questions.

Screening Questions

Pre­-Screen

In-­Office

Do you have a fever or have felt hot or feverish anytime in the last two weeks?

Patient temperature at appointment:

If elevated, provide mask to patient.
Field is required!
Field is required!
Field is required!

Do you have any of these symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose?

Field is required!
Field is required!

Have you experienced a recent loss of smell or taste?

Field is required!
Field is required!

Have you been in contact with any confirmed COVID­19 positive patients, or persons self­isolating because of a determined risk for COVID­19?

Field is required!
Field is required!

Have you returned from travel outside of Canada in the last 14 days?

Field is required!
Field is required!

Have you returned from travel within Canada from a location known affected with COVID­19?

Field is required!
Field is required!

Are you over the age of 60?

Field is required!
Field is required!

Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto­immune disorder?

Field is required!
Field is required!

  • Any “yes” response must be discussed with the managing dentist immediately.

  • Tell the patient when they arrive at the office, they will be asked to:

o Sanitize their hands.
o Answer the questions again.
o Have their temperature taken.
o Complete a form acknowledging the risk of COVID­19.

  • Advise the patient:

o Only patients are allowed to come to the office.
o If possible, to wait in their car until their appointment, call the office when they arrive

Check Us Out on Social Media

Book Now

Field is required!
Field is required!
Field is required!
Field is required!
  • Preferred time slot
  • 9 a.m - 10 a.m
  • 10 a.m - 11 a.m
  • 11 a.m - 12 p.m
  • 12 p.m - 1 p.m
  • 1 p.m - 2 p.m
  • 2 p.m - 3 p.m
  • 3 p.m - 4 p.m
  • 4 p.m - 5 p.m
  • 5 p.m - 6 p.m
  • 6 p.m - 7 p.m
Field is required!
  • Preferred day
  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday
Field is required!
Field is required!

Patient Reviews

Awesome company
Image is not available
Carina Barros

Awesome company and super friendly staff!

Very good team!
Image is not available
Breanna Thorn

I went to Stroud dental on monday for the first time in 13 years..... I was so afraid to go. The experience was amazing. They made me feel comfortable. Jess is very good at her job and gentle. I didnt feel embarrassed or shamed at all. They made sure I got my x Ray's up to date and informed me, my old x Ray's had baby teeth in them. Very good team! Happy I went in and faced my fears.

We highly recommend Stroud Dental!
Image is not available
Shawna Toole

My husband is terrified of going to the dentist and after convincing him to go to Stroud Dental for the first time he has now been 3 times! The staff is absolutely amazing and made him feel safe and comfortable! He actually looks forward to going to the dentist now. Dr. Peleg rocks and the girls are a hoot. We highly recommend Stroud Dental!

The best experience I have ever had!
Image is not available
Cassandra Dickson

Stroud dental was the best experience I have ever had! The staff are very knowledgeable and friendly, it was very clean, fast and efficient. thank you for making my smile beautiful! I would highly recommend this dental office.

A wonderful place to bring your children.
Image is not available
Logan Beau

Stroud Dental is a wonderful place to bring your children. The staff are amazing with my sons, one of which is on the autism spectrum. They are patient and understanding of his quirks. If you’re looking for a great place for dental work check out Stroud Dental.

We couldn’t be more happy.
Image is not available
Keith Shay Smeets

We have been patients of Stroud Dental for over five years!
They have the most amazing team, who make you feel comfortable, welcomed and part of their family!
They are so patient with our 15 month old daughter, and us!
We couldn’t be more happy with everyone at Stroud Dental!

Family, friendly!
Image is not available
Dana Donaldson

Family, friendly! Have always been great with my kids. Always a pleasant experience.

previous arrow
next arrow
Slider

Get In Touch With Us

Call Now Button