Covid Pre-screening Form

Covid Pre-screening Form

Dear Patient,

We’re looking forward to seeing you at your upcoming dental appointment.

Please be advised of the following:

Our office complies with the State Health Department and CDC guidelines to prevent the COVID-19 virus.
Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge.
In order to reduce the risk of spreading COVID 19, we have asked you a number of “screening” questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.

Covid Pre-screening Form




    Do you or have you had a fever of above 100 degrees in the past three days? *
    Do you have any shortness of breath? *
    Do you have a sore throat? *
    Do you have a dry cough? *
    Do you have a runny nose? *
    Have you been in contact with someone positive for Covid-19 (corona virus?) in the last two weeks? *
    Have you tested positive for Covid-19 or are you awaiting test results for Covid-19 within the last 10 days? *