Survey | Yaletown Cosmetic Dentistry

Have you experienced any of the following symptoms of COVID-19 within the last 14 days? Cough, sore throat, shortness of breath, muscle pain, runny nose, sneezing, loss of smell with or without feverYesNo

Have you been in close contact or have been in isolation with a suspected or confirmed case of COVID-19 in the last 14 days?YesNo

Have you travelled internationally in the last 14 days?YesNo

Name

Date

I, verify that the answer I provided on this form to be truthful and honest. It is my responsibility to notify the office if any of the answer changes before my appointmentYesNo

Monday:	11:30am to 7:30pm
Tuesday	8:00am - 5:00pm
Wednesday:	8:00am - 5:00pm
Thursday:	9:00am - 6:00pm
Friday:	8:00am - 12:00pm
One Saturday per Month:	9:00am - 4:00pm