Patient Screening Form

Patient Pre-Appointment Screening

To protect the health and wellness of everyone, please fill-out and submit the below questionnaire for each patient prior to your appointment.

Positive responses to any of these questions will likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

*For COVID-19 testing, see the list of State and Territorial Health Department Websites for your specific area's information.

Due to the high cost of Personal Protective Equipment a $10 fee will be applied to all patients. If you have insurance this fee will be submitted to your insurance company.

NOTICE: Face coverings/masks are currently required. Please bring a face covering with you to your appointment.

Patient Screening questionnaire

Dr. Mark Grucella and Dr. James George Family Dentistry

3 Area Dentist Office Locations:

Fairlawn and Lakemore Dentist Offices Telephone: 330-733-7911

Canton Dentist Office Telephone: 330-454-7700

Patient Pre-Appointment Screening

Patient Screening questionnaire

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