Patient Pre- Screening Form

Capitol Hill Dental Clinic

(604) 299 -8491 email: info@capitolhilldental.ca
Do you have any of the following conditons?

Severe difficulty of breathing Severe chest pain Fever Cough Sneezing Sore throat Ordered to self isolate Recent international travel Diagnosed with Corona Virus
What kind of appointment are you looking for? Are you experiencing any pain? If any infection, swelling, bleeding or trauma, please explain the situation: *
How bad is the pain? How do you rate it on a scale 1 (mild) - 10 (severe); (ONLY IF YOU HAVE PAIN)

1 2 3 4 5 6 7 8 9 10
Please upload a PHOTO/X-RAY of the situation if possible:****(by having pictures, we can facilitate your appointment booking process)****

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Cancel of
Current dentist's name and number:
Current physician's name and number:
Please list all prescription and over the counter medications that you are taking including the name, dosage, purpose and time of the day taken. Please say "NO MEDICATION" if not. *
Are you allergic to or had a reaction to the following:

Local anesthetics Codeine or other narcotics Latex Penicillin or any antibiotics Sulfa drugs Metals Hay fever Iodine Barbiturates
Full Name *

First Name Last Name
Phone *

Area Code Phone Number
E-mail
Signature

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Capitol Hill Dental Clinic