Patient Advisory and Acknowledgment

Receiving Dental Treatment During the COVID-19 Pandemic

Dear Patient:

In order to reduce the risk of spreading COVID-19, we have asked you a number of “screening” questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.


It is important that you disclose to the office any indication of having been exposed to COVID-19. PLEASE share whether you have experienced any signs or symptoms.

1. Have you tested positive for COIVD-19?
If yes, have you been cleared by your physician?
2. Have you been tested for COVID-19 and are awaiting results?
3. Have you had close contact with someone diagnosed with COVID-19 or with symptoms?
4. Have you traveled by plane, train, bus or cruise ship in the last 21 days?
5. Are you currently experiencing or have experienced within the last 3 weeks:
• Cough
• Fever
• Runny Nose
• Shortness of breath
• Loss of taste or smell
• Other COVID symptoms
(Sore Throat, Headache, Fatigue, GI Symptoms, Chills)

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.