Creating Gorgeous Smiles

Covid Screening Form

Great teeth, great smile, great life

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 the 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.

Patient/Responsible Party *

First

Last

Date

Please Answer "Yes" or "No" with your initials, to the following questions

ARE YOU CURRENTLY AWAITING THE RESULTS OF A COVID-19 TEST?

Yes
No

DO YOU HAVE A FEVER?

Yes
No

DO YOU HAVE ANY SHORTNESS OF BREATH?

Yes
No

DO YOU HAVE A DRY COUGH?

Yes
No

DO YOU HAVE A RUNNY NOSE?

Yes
No

DO YOU HAVE A SORE THROAT?

Yes
No

DO YOU HAVE SNEEZING, WATERY EYES, AND/OR SINUS PAIN/PRESSURE THAT IS UNUSUAL AND NOT RELATED TO SEASONAL ALLERGIES?

Yes
No

HAVE YOU EXPERIENCED HEADACHES, FATIGUE, OR WEAKNESS?

Yes
No

HAVE YOU LOST YOUR SENSE OF TASTE AND/OR SMELL?

Yes
No

WITHIN THE LAST 14 DAYS, HAVE YOU TRAVELLED TO ANY FOREIGN COUNTRY?

Yes
No

WITHIN THE LAST 14 DAYS, HAVE YOU TRAVELLED WITHIN THE UNITED STATES?

Yes
No

IF SO, WHERE?

Family Smiles & Implant Center

From cosmetic dentistry to full-mouth rehabilitation, our practice is equipped to handle all of your dental needs.

We accept most major insurances. We process claims on behalf of our patients. This saves them time and upfront costs. All major credit cards are accepted as well as Care Credit.

Serving all your family dental needs in Woodcliff Lake, Montvale, Park Ridge, Hillsdale, Westwood, Paramus, Mahwah, and more areas | Accepting new patients.

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Contact Us

Address: Perillo Tour Plaza
577 Chestnut Ridge Rd,
Woodcliff Lake, NJ, 07677

Office: (201)746-9500

Text: (201)614-7676

Email: [email protected]

Our office hours are:
Mon-Fri: 10:00 AM – 8:00 PM
Sat: 9:00 AM – 3:00 PM

Office Visits

Address: directions from Google Maps!

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