Patient Screening Form
Due to COVID-19 events, please answer the following questions regarding your health status. For office use only.  
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For your information:
To accommodate the COVID-19 Pandemic, the following additional upgrades have been made to our office to keep you, your family, and our staff safe.

Positive pressure respirator hoods worn by doctor, hygienists, and assistants
Disposable gowns worn by doctor, hygienists, and assistants
No touch thermometers
Air purifiers have been added to each room
Over-the-patient high volume viral evacuators
HVAC UV lighting for disinfecting
HEPA filters with plasma to clean the air
Ultra-Violet disinfecting of operatories
Biological friendly disinfection spray post-procedures
Medical grade disinfectants
Sneeze guard at reception area
Automatic hand sanitizers and soaps throughout the office

As always, we follow the infection control recommendations of the American Dental Association (ADA), the Center for Disease Control (CDC) and the Occupational Safety & Health Administration (OSHA). A $20 environmental fee will be charged to you at the time of your visit. Your safety is our top priority. Oral health is directly related to your overall health and we are here to provide for your dental needs.

Your first and last name *
Your Cell Phone Number *
Today's Date *
Have you previously been diagnosed with COVID-19, or do you think you’ve had/have COVID-19? *
 If YES, when and how were you confirmed positive?
Do you currently have (or have you experienced) any of the following symptoms in the past 21 days (check all that apply) *
Are you in contact with anyone who has been sick and/or confirmed to be COVID-19–positive? *
In the past 14 days have you traveled outside the US? *
Are you over the age of 65? *
Do you have high blood pressure? *
Do you have diabetes? *
Do you have respiratory conditions? *
Are you immunocompromised? *
If you are immunocompromised, please list your diagnosis below:
By typing my first and last name below, it serves as my signature, and I consent to treatment during the COVID-19 Pandemic. If signing for a minor, please state your relationship. *
2021 HIPAA OMNIBUS RULE FORM (only fill out one time/year)
If you have already filled out this 2021 Hippa Omnibus Rule form, please scroll to the bottom and submit only your COVID questionnaire.


You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims.

How do you want to be addressed when summoned from reception area?
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Please list any other parties who are actively involved in your healthcare and who can have access to your health information (This includes step parents, grandparents and any care takers who can have access to this patient’s records):
I authorize contact from this office to confirm my appointments, treatment, billing information via (select all that apply):
I authorize information about my health to be conveyed via:
I approve being contacted about special services, events, fundraising efforts or new health info on behalf of this healthcare facility via:
In electronically signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent. The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR/FACILITIES IN THE FUTURE.
Electronic Signature (first and last name). If signing for minor, please state relationship.
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