Richmond Orthodontic Centre
Please answer the following COVID-19 screening questions within 24 hours of your appointment. If you have any questions, please call our office at (604) 276-8225. [请帮我们在您预约前的24小时内填完以下COVID-19表格。如果您有任何问题,随时联系我们,谢谢!]
Date [预约日期]
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-
Month
-
Day
Year
Date
Patient's Name [姓名]
*
First Name
Last Name
Have you been asked to quarantine or self-isolate (ie. close contact exposure or travel outside of Canada, or awaiting test results)? [请问您有被要求隔离或者自我隔离吗 (比如,密切接触新冠感染患者,在加拿大境外旅游,或者正在等待检测结果)?]
*
Yes [是]
No [不是]
Are you experiencing any COVID-19 symptoms (ie. fever, cough, difficulty breathing, loss of smell, sore throat, body aches, diarrhea, headaches, nausea)? [请问您有任何COVID-19的症状吗 (发烧,咳嗽,呼吸困难,味觉失灵,喉咙酸痛,身体疼痛,腹泻,头疼,恶心)?]
*
Yes [是]
No [不是]
Is anyone in your household experiencing COVID-19 symptoms or tested positive for COVID-19? [请问您的家人有出现COVID-19的症状,或COVID-19检测呈阳性?]
*
Yes [是]
No [不是]
Please call our office if you answered yes to any of these questions. Thank you! [如果上述任何一个问题回答的是“是”,请及时联系我们,谢谢!]
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