Covid-19 Patient Screening Form

Please Read Below, Important Covid-19 Information

Pre- Appointment Screening Form:

Prior to your child’s appointment, we will require a Pre-Appointment Screening Form be filled out by the parent.  Our staff will conduct a preliminary screening when confirming a day or two prior to the scheduled appointment date. This may seem repetitive, however it is important to screen our patients thoroughly to prevent possible transmission of disease. Please bring this form to the appointment.

If the answer is “yes” to any of the questions below please call the office a 808-487-1000 to discuss further.

Pre-Appointment Information:

We kindly ask that you are prepared with the following for your child’s appointment:

1. We may ask that you wait in the car until it is your appointment time.

2. A mask is required for each person entering our office.

3. Please be prepared for a temperature check upon entering our office.

4. Please sanitize your hands upon entering our office. Our office will provide hand sanitizer.

5. We ask that only one parent accompany the patient to their appointment. Please do not bring other children or companions who do not have appointments that day. This is to limit the amount of people in the reception area.

6. Please be prepared to fill out an In-Office Screening Form, a repeat of the Pre-Appointment Screening Form.

7. Bring a personal pen to use in our office to prevent cross contamination.

8. Each patient must bring their own pair of safety glasses, goggles, or sunglasses to use for eye protection during their appointment.

9. Please have your child’s teeth brushed thoroughly the night before the appointment and brush right before coming to the appointment. This is to lower the plaque levels in the mouth which can potentially decrease bacterial and viral transmission.

10. Please be prepared to have your child rinse with a pre-procedural rinse of 1% hydrogen peroxide to decrease bacteria and virus levels before exams and procedures.

We understand that these requirements may seem strange from what you may be used to.  Please be assured that it is all being done out of an abundance of concern for our patients’ health, as well as that of the other patients being seen in the office, the doctor and the staff, and any public with whom they might come in contact.  

Please be assured that we will take extra measures to disinfect and sanitize our office and reception area by wiping contact areas regularly throughout the day.