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.