Patient Screening Form

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For the safety of our team, other patients, and yourself, please be truthful and candid in your answers.

If you have been exposed to a communicable disease, you may spread the disease to the dentist, dental staff, or other patients/parents in the practice. Therefore, prior to each appointment, we will be asking the following questions to reduce the chances of transmission:

Do you have any of the following symptoms:

- Any "yes" response will need to be discussed.
- When arriving to the office, you will be asked to:
- Sanitize your hands
- Answer the questions again
- Possibly of having your temperature taken
- Complete a form acknowledging the risk of COVID-19

- Please Note:
- Only patients are allowed to come to the office
- If possible, to wait in your car until their appointment, call the office when you arrive