COVID Pre-Screening Form

Our COVID pre-screening form requires you to confirm each question. If there is an area you are unable to answer or have questions regarding the contents, please contact the office as soon as possible to review.


  • Fever > 38, new onset of cough or worsening of a chronic cough, shortness of breath, decrease or lost sense of taste or smell FOR ADULTS OVER THE AGE OF 18: unexplained fatigue/lethargy/malaise/muscle aches (myalgias) FOR CHILDREN UNDER THE AGE OF 17: nausea/vomiting and/or diarrhea
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  • I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have the above-listed emergency or routine dental treatment completed during the COVID-19 pandemic.
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