COVID-19 Pre-Screening Questionnaire

Here at Connecticut Family Dental, our goal is to provide a safe environment for our patients and staff, and to advance the safety of our local community.  

Patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstances of the COVID-19 virus.  

We thanks you for taking the time to complete the mandatory COVID-19 Pre-Screening Questionnaire.

In our efforts to make your dental visits safe and for the safety of our staff and patients, here are a few additional measures we are requesting your support with:

• Mask:  We request our patients to come to their dental visits with a mask.
• Car: To adhere to social distancing guidelines, seating in our reception is reduced.  Please stay in your car.  Our team will call and request you to come in soon as the staff and doctors are ready.  In the case this is not an option, we will do our best to accommodate you in our reception.  
• Parent/Guardian:  Unless you are accompanying a child or the patient that needs assistance, we request you to come alone to your dental visit.  
• Review Pre-Screening Questionnaire:  Our staff will re-review the same questions from the pre-screening questionnaire to make sure nothing has changed since the forms were completed.
• Hand-sanitizers:  Hand sanitizers will be available to use and so are the restrooms if you prefer to wash your hands.  We request use of either before handing iPADs (to complete additional forms if required), pens, clipboard, water cups, credit card terminals etc. 
• Temperature:  Our team will record your temperature and summon the clinical team for your treatment.  

We thank you in advance for helping us make our practice a safe environment for yourselves, other patients and our staff.