COVID-19 Release Form

COVID-19 Release Form

In accordance with the guidelines handed down by the government and national dental authorities, our office is required to ask every patient we see during the ongoing pandemic about their possible exposure and possible symptoms of COVID-19. To meet this need, all patients must fill out a COVID-19 Release Form which asks a few simple Yes-or-No questions regarding the common, specific symptoms of the novel coronavirus. To account for the possible development of symptoms between appointments, a form must be filled out within 24 hours of each appointment.

If you are exhibiting symptoms of COVID-19, we will put your appointment on hold until you are symptom-free for 14 days.

If absolutely necessary, the COVID-19 Release Form can be filled out on paper at our office, but it is our preference that forms be filled out and returned to us ahead of your scheduled appointment. One way to do this is to download a digital copy of the form from our Patient Forms webpage (available in PDF and DOCX formats), fill it out, and return it to us via email to

For your convenience, we also offer this online form—seen below—which will submit directly to us when completed.

If you wish to use this online form, please take a moment to review it and fill it out completely. When you have finished answering every question, press the Submit button at the bottom of the page. A digital copy of the form will be sent to our office and added to your record.

Please take care to correctly and accurately fill out the patient's name (and if required, the responsible party's name). If we are unable to determine who the form belongs to then we will require you to fill out a paper version of the form in-person before you are seen.

Patient Advisory and Acknowledgment

Receiving Dental Treatment During the COVID-19 Pandemic

Dear Patient:

You have come 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:

While our office complies with State Health Department and the Centers for Disease Control and Prevention infection control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees.

Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge.

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.

Please enter the patient's name.

(if not patient)

The date must be today's date Eastern time.

Please Answer "Yes" or "No" to all the following questions:

Are you currently awaiting the results of a COVID-19 test?
Do you have a fever?
Do you have any shortness of breath?
Do you have a dry cough?
Do you have a runny nose?
Do you have a sore throat?
Do you have sneezing, watery eyes, and/or sinus pain/pressure that is unusual and not related to seasonal allergies?
Have you experienced headaches, fatigue, or weakness?
Have you lost your sense of taste and/or smell?
Within the last 14 days, have you travelled to any foreign country?
Within the last 14 days, have you travelled within the United States?

Please enter where you have recently travelled.