Patient Screening Form




PatientOther



YesNo


YesNo


YesNo


YesNo


YesNo


YesNo


YesNo


YesNo


Any "Yes" response must be discussed with the managing dentist immediately.

When you arrive at the office, you will be asked to:

  • Sanitize your hands.
  • Have your temperature taken.
  • Complete a form acknowledging the risk of COVID-19.

Please be advised:

  • Only patients are allowed to come to the office.
  • If possible, please wait in your car until your appointment, and call the office when you arrive to let us know you are waiting nearby.