COVID-19 Patient Screening

Please answer the following questions to ensure you are COVID-19 symptom free.

2. Do you have or recently have had (within 10-14 days) any of the following symptoms:


Please wear a mask to your scheduled appointment, if you do not have one will be provided.


Acknowledgement and Consent During Covid-19

• I have received information about Covid-19
• I acknowledge that I have informed the dental practice if I have ANY of these symptoms or risk factors.
• I accept that while the risk of transmission of the virus in a dental office setting is low, the risk is not zero.
• I understand that the dental treatment options may be limited during this time to reduce/eliminate the risk of transmission.
• I know I have the right to ask questions about this form and to have those questions answered to my satisfaction.
• By clicking the "submit" button you acknowledge and consent to the above and this will be used as your digital signature.

Book your next appointment today!

We look forward to meeting you and your family.

Request Appointment

(519) 681-4020