Please fill out the form below before coming in for your dental procedure.

Please note – patients are required to wear a mask prior to entering the dental office. 

Patient Screening Form

    Patients who are well but who have a sick family member at home with COVID-19 should postpone their appointment.
  • Special Notice

    Positive responses to any of these questions would likely indicate a need for a deeper discussion with the dentist before proceeding with your appointment.