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You. Your Health. Your Confidence.

Patient Screening Form

Special Notice

Positive responses to any of these questions would likely indicate a need for a deeper discussion with Dr. Singh before proceeding with your appointment. Failure to disclose accurate information prior to your visit could result in cancellation of your appointment upon arrival which may incur an $80 cancellation fee.
Patient Name*
First Last
Are you fully vaccinated?*
According to the CDC, about two weeks after your final dose (first for Johnson & Johnson, second for Pfizer and Moderna) you are considered "fully protected".
- Yes
- No
Have you traveled by plane in the past 14 days to any regions outside of the city in which you reside?*
- Yes
- No
Have you received a negative COVID-19 test upon returning from your flight?
- Yes
- No
Do you have a fever or have you felt hot or feverish in the last 14-21 days?*
- Yes
- No
Are you experiencing shortness of breath or other difficulties breathing?*
- Yes
- No
Do you have a cough?*
- Yes
- No
Are you experiencing any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?*
- Yes
- No
Are you 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 postpone their appointment.
- Yes
- No
SPECIAL NOTICE
Based on your positive response to any of the above questions, a deeper discussion is needed with the Dentist prior to scheduling your appointment. Please call our office today at (206) 323-3830.

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We feel there is only one way to practice dentistry - with compassion, trust, and clinical excellence. We look forward to knowing you as friends as well as patients.

Our Services

To ensure your comfort and peace of mind, we offer stereo headphones to listen to music while enjoying a warm massage chair.

Our Location

We are conveniently located on First Hill, catering to Belltown, Downtown Seattle, Queen Anne, Ballard, Capitol Hill and other neighboring areas. A convenient parking garage is attached to the building.

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It is our goal to meet or exceed the needs of each patient through a unique blend of skills, insight, understanding and artistry. Please call us for any questions you may have about our office or the services that we provide.

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