Appointment Confirmation

Please complete the wellness survey below and click submit when you are done.

NOTE: If you have not received our arrival policy via email, please click here to review and print.

Please complete the wellness survey below and click submit when you are done.

Your Full Name:

Best number to send/receive text messages regarding your appointment:

Have you run a fever or had flu-like symptoms in the last 72 hours?

Are you currently displaying any of the following symptoms?

Have you been exposed to anyone who has tested positive or exhibited symptoms related to the Covid-19 in the last 14 days?

Have you tested positive for Covid-19?

If yes, how many days have you been symptom free?

Any additional concerns or needs you'd like to share prior to your visit?

Opt-In

I acknowledge the importance of protecting the health of my dental provider and other patients. I confirm that all answers I have given above are true to the best of my knowledge.

Opt-In

I have reviewed and understand the office policies and procedures related to Covid-19. I understand that if I am more than 10 minutes late to my appointment that I will need to reschedule and may be charged a $55 late cancelation fee.

Appointment Confirmation

Appointment Confirmation

Please complete the wellness survey below and click submit when you are done.

Ready To Start Your Journey With Us?