Health pre-screening

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 it to the dentist, dental staff, or other patients in the practice. Prior to each appointment, we ask the following questions to reduce the chances of transmission.

First name

Last name

Exposure & travel

Leave blank if the answer is no

Have you, your child, or others accompanying you to today's appointment tested positive for or been diagnosed as having COVID-19 or any other communicable disease? If yes, when?

Have you, or anyone you have come into contact with, traveled out of state or outside of the country within the last 21 days? If yes, where?

Flu-like symptoms

Within the past 14–21 days — please answer every question

I understand that I am obligated to answer these questions truthfully. I also understand that if the answer to any of these questions is yes, I may be asked to reschedule today's dental appointment.

Signature (type your full legal name)

Date

Typing your name acts as your electronic signature and has the same effect as a handwritten one.

Health Pre-Screening Form