Patient Advisory and Acknowledgment

Receiving Dental Treatment During the COVID-19 Pandemic

Dear Patient:

You have presented to our office today for a routine dental evaluation and/or treatment that will be done during the COVID-19 pandemic. Please be advised of the following:

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.


Are you currently awaiting the results of a COVID-19 test?
Are you in contact with any confirmed COVID-19 positive patients?
Do you have a fever or have you felt hot or feverish recently (14-21 days)?
Do you have any shortness of breath or other difficulties breathing?
Do you have a cough?
Any other flu-like symptoms, such as gastrointestinal upset, diarrhea, headache or fatigue?
Do you have sneezing, runny nose, watery eyes, and/or sinus pain/pressure that is unusual and not related to seasonal allergies?
Have you experienced recent loss of taste or smell?
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Within the last 14 days, have you travelled to any foreign country or any regions affected by COVID-19?