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COVID-19 FORM

SCREENING
FOR YOUR
SAFETY

Our office adheres to all infection control recommendations made by the American Dental Association (ADA), the U.S. Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA). One of the key new requirements is to screen anyone entering our office with the following COVID-19 Screening Form. This questionnaire must be filled out and signed electronically BEFORE any patient comes in the office. If any answers are “YES”, we must reschedule for a later date for everyone’s safety.

  • Thank you for putting your trust in our office and we are so glad we are able to see you again. This form allows us to screen for communicable diseases including COVID-19 in our office in an effort to keep all our patients and team safe. For each appointment, we will need you to answer the questions below. Any 'yes' answer to a question, means that we will need to reschedule your appointment at a later date.
  • This field is for validation purposes and should be left unchanged.
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