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, have you felt hot or feverish or experienced chills 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 a sore throat or muscle pain?
Within the last 14 days, have you travelled to any foreign country or any regions affected by COVID-19?

If you answered "yes" to any of the above questions, please contact our office at (856) 582-1000 prior to your appointment to discuss.