COVID-19 Screening Form

Your health and safety are our top priority! The team at Wihlm Dental has made some changes to your upcoming appointment:

  • When you arrive for your appointment, please remain in your car and call us at 920-231-0060 or text us at 920-228-8248. We will check you into our system, and then call or text you when we are ready for you to come into the office. 

  • Please wear a mask to our office and use the provided hand sanitizer as you enter our office. 

  • Our waiting room is essentially closed. We ask that you leave your companions either at home or in the vehicle during your appointment. Exceptions will be made for patients that require a parent, guardian or caretaker with them. In these cases, please just bring one companion, who will also require screening upon arrival. 

  • We have removed any community items (magazines, toys, books, coffee, etc) from our waiting area. We hope this is a temporary modification and look forward to re-introducing the more comfortable waiting room you are accustomed to in the future. 

  • Additionally, our team members are disinfecting all areas of the office on an even more regular basis than in the past. We will also be wearing masks while in the office. 

Please complete the PRE-APPOINTMENT screening questions and consent below at least one day prior to your appointment. Please complete one form per scheduled patient.





Consent to treatment:

You understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. 

Wihlm Dental has always made patient safety a top priority. We continue to follow state and federal regulations and the recommended universal personal protection and disinfection protocols to reduce the risk of transmission of any diseases in our office. There are several modes of transmission of COVID-19 which could be present in a dental office. Wihlm Dental is following the ADA and CDC guidelines to minimize the risk of transmission. 

Despite our close attention to sterilization and disinfection you understand that due to the frequency of visits of other dental patients, the characteristics of the virus, and the characteristics of dental procedures, that you have an elevated risk of contracting the virus simply by being in a dental office. 

The CDC recommends social distancing of at least 6 feet. Wihlm Dental is committed to taking all reasonable measures to allow for social distancing in our office, however, due to the treatment you are receiving it is impossible to maintain this distance at all times between the dentists, dental team members and sometimes other patients.  

By checking this box, you acknowledge that you have answered the above screening questions honestly and you knowingly and willingly consent to have dental treatment completed at Wihlm Dental during the COVID-19 pandemic. 

I consent to treatment