Patient Advisory and Acknowledgment

Receiving Dental Treatment During the COVID-19 Pandemic

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-19 Questionnaire

    First Name

    Last Name

    Do you have a fever?

    Do you have any shortness of breath?

    Do you have a dry cough?

    Do you have a runny nose?

    Do you have a sore throat?

    In the last 14 days, have you travelled to any foreign country?

    In the last 14 days, have you travelled within the United States?

    If so, where?