Screening Questionnaire

"*" indicates required fields

Dr. Peter Pessinis - General and Cosmetic Dentistry

Patient Screening Form

To be completed prior to appointment.

Patient Name*
Guardian Name
(Required if patient under the age of 18.)

Please note the following:

  • Upon arrival to the office, please sanitize your hands.
  • The receptionist will come around to check your temperature and ask the following pre-screening questions again once you are in the office.

1. Have you had any Covid 19, cold or flu symptoms in the last 7 days?*
2. Have you been in contact with any confirmed COVID-19 positive individuals in the last 5 days?*
This field is for validation purposes and should be left unchanged.