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 treating our patients 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 Patient Wellness Form below before their upcoming appointment. We will need to have these forms completed in order to see you. In some cases, we may need to reschedule your appointment to a later date, for your safety and that of our team and other patients.

Call or Text on Arrival: At this time, our reception area is closed to visitors. To limit exposure, we are asking that only those with an appointment come in to the office. With the exception of guardians and translators, additional guests will be asked to wait outside. To help with social distancing and the pre-screening process, please arrive 5-10 minutes early to your appointment and remain in your car. Send us a text reply and/or call us when you arrive. We will text or call you when we are ready for you to come to our screening station.

Wear a Mask: We are asking that all patients and guardians wear a face mask (or face covering) when they arrive to our practice. While we have missed you and would like nothing more than to share hugs and handshakes, 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. 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 to appointments to sanitize and sterilize all equipment and surfaces as well.

Check-Out: In many cases, our staff will schedule your next appointment at chairside, take any additional payment due, and answer any administrative questions. We will do our best to keep the process as contactless as possible.

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

Patient Wellness Form

This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstances of COVID-19. A weak or compromised immune system (including conditions like diabetes, asthma, COPD, cancer treatment, and other diseases and medical conditions) can put you at greater risk for contracting COVID-19. Please disclose any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment for your safety and wellness.

It is also important that you disclose to this office any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with COVID-19.

By signing this form, you knowingly and willingly consent to having dental treatment at New Day Dentistry PLLC. You further understand that COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious, and 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.

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 confirm that I have not tested positive for COVID-19 IN THE PAST 14 DAYS*

I confirm that I AM NOT awaiting my results FROM A RECENT COVID-19 TEST*

I understand that air travel, travel by cruise ship, bus or train, and visiting densely populated spaces greatly increases my risk of contracting and transmitting the COVID-19 virus. I confirm that I have not traveled outside of the USA or domestically, by air, cruise ship, 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, LOSS or REDUCTION OF SMELL/TASTE, or SORE THROAT*

I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system. The answers I have provided above are true and accurate and I have had the opportunity to discuss my care to my satisfaction. I agree that by printing my name below I am electronically signing these forms.


Thank You!

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