Patient Screening Form

Please fill out our patient review form to book your appointment.

    Patient Name:


    Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?

    Are you/they having shortness of breath or other difficulties breathing?

    Do you/they have a cough?

    Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

    Have you/they experienced recent loss of taste or smell?

    Are you/they in contact with any confirmed COVID-19 positive patients?
    Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

    Is your/their age over 60?

    Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

    Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)

    [hidden thank-you-url “/thank-you-for-your-request/”]

    Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

    For testing, see the list of State and Territorial Health Department Websites for your specific area’s information