New Patient Offer
Teeth Whitening
Special Offer

Receive a Complimentary Invisalign Consultation!
(value of $150)

Also receive
Vivera Retainers
with Invisalign Case
(value of $400)

For New Patients Only

Offers cannot be combined.
To take advantage of this amazing offer, simply complete the form below.
Offer Expires 07/12/2020

COVID-19 Patient Screening Form

Patient Name:
Phone Number:
Email Address:
Pre-Appointment In-Office
Date: Date:
Do you/they have fever or have you/they felt hot or feverish, had chills or repeated shaking with chills, or had muscle pain recently (14-21 days)?
Yes No
Yes      No
Temp:______°F
Are you/they having shortness of breath or other difficulties breathing?
Yes No
Yes      No
Do you/they have a cough?
Yes No
Yes      No
Any other flu-like symptoms, such as gastrointestinal upset, headache, fatigue, nasal congestion, or sore throat?
Yes No
Yes      No
Have you/they experienced recent loss of taste or smell?
Yes No
Yes      No
Are you/they in contact with any confirmed COVID-19 positive patients?
Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.
Yes No
Yes      No
Is your/their age over 60?
Yes No
Yes      No
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Yes No
Yes      No
Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)
Yes No
Yes      No
Are you allergic to Iodine or Shellfish
Yes No
Yes      No

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

Medical History Update:

Have you seen a Doctor since your last visit?
Have you been diagnosed with anything new?
Have you had any surgeries since your last visit?
Are you taking any new medications since your last visit?
Please list all medicines, including any over-the-counter, vitamins and/or supplements.
Do you have any dental concerns at this time? Broken tooth? Tooth ache?

Please enter code above in the field below.