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COVID 19 Screening Form and Appointment Instructions
Please complete highlighted boxes

Due to the COVID-19 global pandemic, we ask that you complete this form prior to arriving at our office and click on the SUBMIT button below after completing this form.

We will not be able to accommodate your appointment without having received this before you arrive for your appointment.


In order to safeguard our dental office and the rest of our community, we ask that you arrive at the office wearing a face covering. You will not be allowed entry without a face covering.


If you are experiencing any symptoms related to COVID-19, we ask that you do not come to our office at this time.


Symptoms are indicated as follows: Cough, shortness of breath, or difficulty breathing OR any two of the following: Fever, Chills, Repeated shaking with chills, Muscle pain, Headache, Sore throat, New loss of taste or smell. Note: This list is not all inclusive.


Please consult your medical provider if you have any other severe symptoms that concern you. If you develop any of the following symptoms (warning signs) for COVID-19, seek emergency medical attention immediately: Trouble breathing, Persistent pain or pressure in the chest, New confusion or inability to awaken/focus, Bluish lips or face.

1. Have you traveled anywhere recently that are locations of disease outbreak?

2. Within the last 2 months, have you been in contact with anyone who was sick?

3. Within the last 2 months, have you attended any large group functions?

4. Have you had any of the following symptoms within the last two weeks: fever, fatigue, dry cough, altered taste, altered smell, trouble breathing, productive cough (mucous in cough), or muscle pain?

5. Have you previously had the SARS-COV-2 virus (novel coronavirus or COVID-19)?

5a. If YES, did you test positive for SARS-COV-2 virus?

5b. If YES, were you administered an antibody test?

5c. If YES, were you administered a viral test?

6. Are you over the age of 65?

7. Do you have pre-existing health conditions related to the following:



Chronic Lung Disease

Chronic Kidney Disease

Serious Heart Condition


Auto-immune Disease

High Blood Pressure

Chronic Liver Disease

8. Any other health conditions that you would like to report?

Thanks for submitting!

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