05/14/2020
REQUIREMENTS FOR YOUR NEXT APPOINTMENT
*PRE-SCREENING is required before your appointment. Please review the Patient Screening Form from the ADA. If you answer yes to any of these questions, please contact us.
*Upon arriving to your appointment, please text us your name @ (603) 667-8996 to let us know of your arrival. You will then wait in your car. When your provider is ready to see you, they will text or call you, then greet you at the front lobby/waiting area.
*All patients are required to wear a mask to appointments. Mask should be on before entering the building and at all times other than when in treatment.
It is imperative that your information be updated with us in order for us to reach you by phone, text or email. Please know that we adhere to the highest level of HIPAA regulations and that your information will never be shared.
We thank you for your understanding and look forward to seeing you all again!
ADA Patient Screening Form:
PRE-APPOINTMENT IN-OFFICE
Date: Date:
Do you/they have fever or have you/they felt hot or feverish recently
(14-21 days)? âYes âNo âYes âNo
Are you/they having shortness of breath or other difficulties breathing? âYes âNo âYes âNo
Do you/they have a cough? âYes âNo âYes âNo
Any other flu-like symptoms, such as gastrointestinal upset, headache
or fatigue? âYes âNo âYes âNo
Have you/they experienced recent loss of taste or smell? âYes âNo âYes âNo
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.
âYes âNo âYes âNo
Is your/their age over 60? âYes âNo âYes âNo
Do you/they have heart disease, lung disease, kidney disease,
diabetes or any auto-immune disorders? âYes âNo âYes âNo
Have you/they traveled in the past 14 days to any regions affected
by COVID-19? (as relevant to your location) âYes âNo âYes âNo
Positive responses to any of these would likely indicate a deeper discussion with the dentist before
proceeding with elective dental treatment.
â For testing, see the list of State and Territorial Health Department Websites for your specific areaâs information.