COVID-19 Screening Form

Prior to all dental visits, patients are encouraged to complete the COVID-19 screening form prior to all dental visits. These questions will be reviewed when you arrive at the office for the scheduled appointment.  

  • Only patients should enter the office unless a parent or support person is needed.
  • To help with social distancing, patients should wait in their car until 5 minutes before the scheduled appointment time then you may enter the office.
  • Mask wear is optional and at the discretion of the patient. Our staff will continue to be masked during your visit. 
  • Sanitize hands with the provided hand sanitizer.
1. Are you immunocompromised?

3. Have you been told (by a doctor, healthcare provider, public health unit or government authority) that you should be quarantining, isolating or staying at home?

4. In the last 10 days, have you tested positive for COVID-19 on a laboratory-based PCR test, rapid antigen test or self-testing kit?