Patient Evaluation Form - Must be completed before scheduling or rescheduling visits


Dear Patient,

Our office team is excited to welcome you back now that the moratorium on elective dental treatment is expect to be lifted as of May 31, 2020. As we work through the backlog of appointments we were unable to complete over the last six weeks it is important for you to know we have taken great care to ensure the lowest possible risk of contracting Covid - 19 while a patient in our practice.

Completion of this form is REQUIRED prior to rescheduling your visit at this time as robust screening prior to patient admission into our office is still a high priority. Your patience is greatly appreciated as we take these necessary steps to ensure the safety of our team and our patients at this time.

Your visit may include:

1. Patient Temperature screening
2. Ongoing employee screening to ensure our staff is healthy when treating you
3. Sterilization of the facilities on a daily basis
4. Use of hydrogen peroxide/chlorhexidine oral rinses prior to evaluation
5. Extended appointment times to ensure adequate social distancing of all patients
6. Use of HEPA air filtration, continuously in treatment and common areas
7. Use of N95 respirators or ASTM level III masks combine with polycarbonate face shield
8. Disposable or washable PPE gowns, masks, faceshields, eye protection and n95 respirators (or equiv) for all employees
9. Disinfection of all critical care touch points in the circle of care
10. Providing single use gloves to patients at entry and exit points to the office
11. Posting of signs showing appropriate cough etiquette
12. Taping of the office to show appropriate social distancing requirements
13. Use of specially designed High Volume Evacuation Equipment to reduce aerosol spread in the operatory setting.

If you feel your question may be able to be answered without an in person visit please email us at dentaloffice@gmail.com For new patients please complete the form and you will be contacted to set up a personal visit, virtual visit or appropriate phone call:

Eric Yabu, DDS
Geraldine Lim, DDS
Anita Purohit, DDS

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