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COVID-19 Patient Screening Form

Prior to all dental visits, we are required to complete this form prior to any patient visiting the office. These questions will be asked prior to scheduling an appointment and when the patient arrives at the office for their appointment.

  • Any “YES” response will be discussed with the Dentist upon arrival.

  • Masks are mandatory before entering the office.

  • Only patients should be entering the office unless a parent or support person is needed.

  • To help with social distancing, patients should wait in their car until their scheduled appointment time. No magazines, newspapers or children’s toys will be available.

  • Upon arrival at the office, all patients will be asked to:
    • Wear a mask until seated in a dental chair.

    • Sanitize hands with the provided hand sanitizer.

    • Answer the screening questions.

    • Temperature check with a touch-free thermometer.

(check one)

(please check)

(to be signed in the office)
(to be completed in office)
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