Please fill out the Pre-Appointment Screening Questionnaire below, prior to your dental appointment.

New Office Protocols:

Day Before Your Appointment:

You will be emailed a pre-screening form to review, answer, and sign the day of your appointment. The form can also be found here on our website.

Upon Your Arrival at the Office:

  • Please wait in your car or outside the office until your scheduled appointment time.
  • Your pre-screening will be reviewed BEFORE entering the office.
  • Upon arrival at the clinic, a hand hygiene will be performed.
  • The public areas, including restrooms, will be cleaned, and sterilized frequently throughout the day.
  • Any patients showing symptoms of illness or signs of a fever will be asked to reschedule their appointment.

Your Treatment:

  • All rooms will be COMPLETELY sterilized before each patient is seated.
  • All operatories have high-volume air suction units to help remove debris and air particles.
  • Our team is following all guidelines set forth by the College of Dental Surgeons of British Columbia, The BC Centre for Disease Control, and WorkSafe BC.
  • During patient care, appropriate PPE will be worn.
  • All surfaces that come in contact with the patient will be wiped with disinfectant.
  • As new information becomes available to us, from our dental college, we will be updating our infection control measures.

From Your Kettle Valley Family Dental Team


Pre-Appointment Screening Questions

If you have any signs of cold or flu-like symptoms, please self-isolate and do not visit the dental office until the symptoms are gone. Please understand this form is now routine practice and is required by the British Columbia Dental Association and British Columbia College of Oral Health Professionals.
Are you currently under an order to quarantine or have been told to self-monitor and/or self- isolate by public health following a close contact exposure?(Required)

Please CHECK all that apply:

Do you have any of the following symptoms:(Required)
Have you had any of the following symptoms for more than 24 hours:(Required)

***Symptoms should be new or worsening. ie. unrelated to a known pre-existing medical condition or other circumstances. ***


Have you had a COVID-19 test since any of the above symptom’s onset OR have you been recommended for a test by a health care provider in the last 14 days?
I understand that dental procedures create water spray and aerosols which is one way that the novel coronavirus can spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the novel coronavirus.(Required)
I verify the information I have provided on this form is truthful and accurate.(Required)
Patient Name(Required)
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