Patient Screening Form

Dear Patient:

We hope  you and your family are  in good health. Our community has been through a lot over the last few months, and all of us are looking forward to resuming our normal routines. While many things have changed, one thing has remained the same: our commitment to your safety.

Infection control has always been a top priority for our practice and you may have seen this during your visits to our office. Our infection control processes are made so that when you receive care, it’s both safe and comfortable. We want to tell you about the infection control procedures we follow in our practice to keep patients and staff safe.

Our office follows infection control recommendations made by the American Dental Association (ADA), the U.S. Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA). We follow the activities of these agencies so that we are up-to-date on any new rulings or guidance that may be issued.

When it is time for your next appointment we made changes to help protect our patients and staff.  Please read the following:

*    Upon arriving to the office please type doxy.me/drpniarhos into the web browser on your phone (Safari, Chrome) and follow the instructions using the patient’s name. That will put the patient in a virtual waiting room that our front desk staff can see.

*    Leave the website running and do not enter the office until you are contacted and told to do so.

*    When called sanitize hands with provided hand sanitizer before entering the office.

*    Only the patient/parent will be allowed into the office and must be wearing a mask.

*    Parents must remain in waiting room. No one except staff and patient are permitted in the clinic area.

*   The patient will have their temperature taken with a touchless thermometer before being allowed into the clinic area.

*   Our whole office will be sanitized three times daily with a nontoxic antiviral sanitizer.

*   We will be accommodating any senior patients that would like an early morning appointment a few days a week.  Please call our office.

We look forward to seeing you again and are happy to answer any questions you may have about the steps we take to keep you, and every patient, safe in our practice. 

Thank you for being our patient. We value your trust and loyalty and look forward to welcoming back our patients.

Sincerely,

Dr. Khan and Staff

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
Are you/they having shortness of breath or other difficulties breathing?
Do you/they have a cough?
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Have you/they experienced recent loss of taste or smell?
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.)
Is your/their age over 60?
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)
Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment. • For testing, see the list of State and Territorial Health Department Websites for your specific area’s information.