COVID 19 Patient Screening Form

Due to the COVID 19 pandemic, we ask that you complete this form prior to arriving at our office.

In order to safeguard our dental office, our patients and the rest of the community, we ask that you arrive wearing a face mask. We will provide a face mask for you if you do not have one. We also ask that you call upon arrival so you can be escorted to your treatment room. We ask if you are experiencing any symptoms related to COVID 19, that you call the office to reschedule.

We thank you for your cooperation and we will contact you if we need further information. We can’t wait to see you!

*Please consult your medical provider if you have any other symptoms that concern you.

If you develop any of the following symptoms, seek emergency medical attention immediately: *trouble breathing, persistent pain or pressure in the chest, new confusion or inability to arouse, bluish lips or face*