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Pediatric Dentistry BUTTON REQUEST APPOINTMENT
(503) 284-5678
Now welcoming new patients!

Patient Screening Form



















First Name:*
Last Name:*
Date (MM-DD-YYYY)::*
Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?:* YES  NO
Are you/they having shortness of breath or other difficulties breathing?:* YES  NO
Do you/they have a cough?:* YES  NO
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?:* YES  NO
Have you/they experienced recent loss of taste or smell?:* YES  NO
Are you/they in contact with any confirmed COVID-19 positive patients?:* YES  NO
Is your/their age over 60?:* YES  NO
Have you/they traveled in the past 14 dats to any regions affected by COVID-19? (as relevant to your location):* YES  NO
Please enter the text you see:

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.
•  For testing, see the list of State and Territorial Health Department Websites for your specific area's information.
Pediatric Dentistry MAP NE PORTLAND

Review Us Online:

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(503) 284-5678



2811 NE Wasco St.
Portland, Oregon 97232




Office Hours:

Monday - Thursday
8:00am -5:00pm
Friday
7:00am -3:30pm



Saturday Appointments:
Call for details



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Pediatric Dentistry of Portland, 2811 NE Wasco, Portland, OR 97232 | (503) 284-5678 | pediatricdentistrypc.com | 10/17/2021 | Related Phrases: pediatric dentist Portland OR | pediatric dentist Portland OR |