Pre-Appointment Screening Survey
Please complete your screening survey before your appointment and notify us if any your answers change before your visit.

We ask that you also take your temperature at home one hour prior to your appointment. If you have a fever or are not feeling well, please call our office to reschedule your appointment. Your temperature will also be taken when you arrive at the office.

In efforts to minimize exposure to COVID-19, we ask all patients to attend appointments alone if possible. If family is required for transportation, we ask that they remain in their car during the appointment.

Please contact the office if you experience COVID-19 symptoms within 14 days after your dental appointment.
If you have any questions, please call us at 214-821-5200.
Email address *
Name *
Your answer
Your appointment date
Have you tested positive for Covid-19 or are you awaiting results? *
Do you have a fever greater than 100.4F without taking fever-reducing medication? *
Do you have any of the following respiratory symptoms - cough, shortness of breath, sore throat? *
Have you recently lost your sense of smell or taste? *
Do you have any GI symptoms like diarrhea or nausea? *
Even if you don't currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days? *
Have you come into close contact (within 6 feet) with someone who has tested positive for COVID-19 or is "under investigation" in the last 14 days? *
Have you or a household member traveled to an area with a widespread outbreak of COVID-19? *
Have you or a household member traveled by air, bus, train, or cruise ship in the last 14 days? *
Please add any additional information we may need to know about your answers if necessary.
Your answer
I have completed this form and verify that everything I have completed is true. By typing my full name, I am using that to serve as an electronic signature. *
Your answer
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