• Pre-Appointment Screening Form

    Pre-Appointment Screening Form

  • Laroco | Clínica Dental is taking precautions to avoid further spread of the COVID 19 virus. In light of this, we have instituted additional guidelines and protocols to ensure your safety.

    1. The clinic will be strictly BY APPOINTMENT ONLY. No Walk Ins.

    2. We require ALL PATIENTS to wear a mask upon entering the office.

    3. Bringing of companions are NOT allowed, unless necessary, and only limited to 1 per patient. It is advised that they wait outside the clinic.

    4. Maintain social distancing in the reception area for essential companions if they cannot wait in a vehicle or outside the clinic.

    5. Please come on time. We try to allot enough time for your procedure and in between patients for proper cleaning and disinfection of the operatory. Any delays will affect succeeding appointments.

    6. We will require hand sanitizing and recording of temperature as you enter the clinic.

    7. Please fill out the pre-appointment screening form.

    Thank you!

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (0000) 0000-000.
  • Sex

  • MEDICAL HISTORY

  • A weak immune system can put you at greater risk for contracting COVID-19. Please select the ones that apply.

  • TRAVEL HISTORY

    Please disclose any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus
  • In the past 14 days, have you or any household member travelled to a region with high rates of COVID 19 disease activity?*
  • Are you awaiting results of a lab test for COVID 19?*
  • Have you tested positive for COVID 19?*
  • Have you or a household member previously been asked to self isolate or self-quarantine in the past 14 days?*
  • Have you or any member of your household had any close contact with an individual with COVID 19 infection in the past 14 days?*
  • Do you or have you had any of these symptoms in the last 14 days?*
  • BOOK AN APPOINTMENT
  • Should be Empty: