Wellness Form

To help maintain a safe and healthy environment for our patients and staff, please complete this form within 24 hours prior to your scheduled appointment. If you experience any changes in your health or develop symptoms of a respiratory illness after submitting this form, please notify our office as soon as possible so we can determine whether your appointment needs to be rescheduled.

If you are recovering from a recent respiratory illness, we encourage you to wear a face mask while visiting our office.

Date of your appointment

Date

Name

First NameLast Name

Name of your general dentist

Are you currently experiencing any of the following symptoms that are new or not related to a known medical condition?

Have you experienced fever or symptoms of a respiratory illness within the past 24 hours?

Have you tested possitive for COVID-19, influenza (flu), RSV, or another contagious respiratory infection within the past 10 days?

Patient Wellness Screening Form

A positive response does not automatically mean your appointment will be canceled. Our clinical team will review your symptoms and determine the appropriate next steps.