COVID-19 Pre-screening Form

  • Port Jefferson Station, NY - 140 Terryville Rd 11776
  • Port Jefferson Station, NY - 5225 Nesconset Hwy 11776
  • East Patchogue, NY - 250 Patchogue-Yaphank Road, Suite 8 11772
  • (631) 473-3094 | Port Jefferson Station, NY - 140 Terryville Rd
  • (631) 474-1216 | Port Jefferson Station, NY - 5225 Nesconset Hwy
  • Phone (631) 758-8400 | East Patchogue, NY - 250 Patchogue-Yaphank Road, Suite 8

Please open the link below, print, fill out on the day of your appointment and bring with you to your dental visit.

As a reminder, at this time we request that, whenever possible, only the scheduled patient come to the office in an effort to maintain social distancing guidelines.  We appreciate your understanding. 

 

COVID-19 Pre-screen.pdf

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