Active Life Dentistry
Appointment Check-in Form
Cypress/Skinner Rd.

Welcome to Active Life Dentistry! Once you have arrived outside the ALD office, please wait in your vehicle and fill out and submit the form below. If you have a permitted companion coming inside with you (see below), please have them fill out the form as well.
Please come inside at your scheduled appointment time but not before.

Please complete the form below. All Fields are required.
Untitled Document

Patient Name:

Patient Date of Birth: (in 00/00/000 format)

Name of Person Filling Out This Form:

Appointment Time:

Make, Model and Color of Car:

Phone Number:

Email address for notices/billing:

Change of Insurance?
Yes No

If Yes, please provide your new insurance information to our office staff when you enter for your appointment.

Effective as of May 1, 2020, by law, no person (including the patient's minor children) may accompany the patient into the dental office unless the patient requires assistance (e.g. the patient is a minor under age 18, has special needs, is elderly and needs assistance, needs a translator, etc.). If the patient requires assistance, ONE companion may accompany the patient into the office.

Does the patient require assistance and will they have someone come with them into the office?
Yes No

If so, what is their name?

We are required by law to screen all persons entering our dental office for possible signs, symptoms or exposure to COVID-19, including taking a temperature reading. Please read carefully and answer each of the following questions.
You will need to complete separate forms for each patient and any companion permitted to accompany the patient.

The following questions are being answered by/on behalf of:
Patient Companion

1. Have you been diagnosed with COVID-19 in the past 14 days?
Yes No

2. Have you been tested, or recommended by a physician to be tested, for COVID-19 in the past 14 days?
Yes No

3. Do you have any symptoms of influenza or acute respiratory illness, or symptoms of any other illness, without the use of symptom-altering medicines (e.g. cough suppressants), at any time within the past 72 hours?
Yes No

4. Do you currently have, or have you had at any time within the past 72 hours, a fever (100.0 F or greater), or signs of a fever, without the use of fever-reducing medicines?
Yes No

5. In the past 72 hours, have you experienced any of the following signs or symptoms that are either new or worse than normal if you already (i.e. prior to March 2020) experience them to some degree: Cough - Shortness of breath or difficulty breathing - Chills - Repeated shaking with chills - Muscle pain - Headache - Sore throat - Loss of taste or smell - Diarrhea?
Yes No

6. Have you travelled outside the United States in the past 14 days by any means (e.g. airplane, cruise, car, etc.)?
Yes No

7. Have you travelled to any other area or region under a governmental order or recommendation to self-quarantine (e.g. Italy, China, Iran, most countries in Europe), in the past 14 days?
Yes No

8. Can anyone who resides with you or with whom you have had close contact in the past 14 days answer "YES" to any of the above questions?
Yes No

By clicking the "Check In" button below, you (i) certify that you have read and understand this form, (ii) certify that all of the answers given above are true, correct and complete, (iii) acknowledge your understanding that we are required to report to the local health department any individual who enters our office and exhibits symptoms of COVID-19, and (iv) consent to have your temperature taken by an ALD staff member before entering the office. You agree that clicking the "Check In" button below will serve as your binding electronic signature to the matters set forth above.