New Day Dentistry
Patient Medical & Wellness Form

Dear Friends and Valued Patients,

We welcome you back and are thrilled to see everyone again!

As we do our best to navigate safely re-opening our practice during these unprecedented times, we wanted to give you a better idea of what to expect when you come to your dental appointment.

Forms: Everyone will be asked to complete the Health & Wellness Forms below before your upcoming appointment. We will need to have these forms completed in order to see you. If you are experiencing any of the COVID-19 symptoms indicated below, or if your forms are not completed before your appointment, we will reschedule your appointment for a future date.

Call or Text on Arrival: At this time, our reception area is closed to visitors. To help with social distancing and the pre-screening process, please arrive 10 minutes early to your appointment and remain in your car. Send us a text reply or call us when you arrive. We will text or call you when we are ready for you to come to our screening station. To limit exposure, we are asking that only those with an appointment come in to the office. Additional guests will be asked to wait outside.

Wear a Mask: We are asking that all patients and guardians wear a face mask (or the like) when they arrive to our practice. While we have missed you and would like nothing more than to hug you or shake your hand, please understand that for your safety, we are limiting physical contact at this time.

Screening Station: The screening station will be set-up in our reception area, before you enter the treatment room. You will be asked if any of the information on the forms you completed has changed. We will also be taking the temperature of each patient and parent with a touchless and/or forehead thermometer to verify nobody has a fever. Please let us know in advance if you tend to run hot/cold!

Limited Capacity: At this time we are scheduling at a limited capacity and we will do everything possible to ensure our patients maintain proper social distancing during their appointments.

Cleanliness: We have always maintained the highest standards when it comes to sterilization and cleanliness, but we have added additional safety measures. We have added extra time in between appointments to sanitize and sterilize all equipment and surfaces as well.

Check-Out: Our staff will come to you in the treatment room to schedule your next appointment, take any additional payment due, and answer any administrative questions. We will try to keep the process as contactless as possible.

We appreciate your patience while we modify and perfect our protocols.

Patient Wellness Form



knowingly and willingly consent to having dental treatment at New Day Dentistry PLLC. I understand that COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine with certainty who has it and who does not, given the current limits in virus testing, dormant symptoms, and slow test results.

Dental procedures create water spray which is one of the ways the disease is spread. The ultra-fine nature of the spray can linger in the air and on surfaces for up to several hours, which can transmit the COVID-19 virus. While every measure is taken to maintain a sterile and clean environment, no guarantees can be made as these water particles may linger in the air.

I confirm that I have not been around anyone who has tested positive for COVID-19, has virus-like symptoms or has been quarantined

I understand that air travel, travel by bus or train, or travel to the mountains greatly increases my risk of contracting and transmitting the COVID-19 virus and the CDC recommends social distancing of 6ft for 14 days to anyone who has. I understand social distancing is not possible during a dental procedure. I confirm that I have not traveled to the mountains, outside the USA or domestically, by air, train or bus in the past 14 days

I confirm that I am not presenting with any of the symptoms of COVID-19 including FEVER, SHORTNESS OF BREATH, DRY COUGH, RUNNY NOSE or SORE THROAT

I understand that due to the characteristics of the virus and of dental procedures, I have a elevated risk of contracting the virus simply by being in a dental office. I am willingly proceeding with treatment for the benefit of my dental and overall health and release my dentist of liability pertaining to COVID-19


Thank You!

We appreciate you taking the time to complete this form. We'll be in touch with you regarding your appointment shortly.