COVID-19 Form


Dear Patient,

You are scheduled for routine dental evaluation and/or treatment that will be done during the COVID-19 pandemic. Please be advised of the following:

  • While our office is following and complying with the 'Ohio State Health Department', and the 'Centers for Disease Control and Prevention' for their infection control guidelines, to prevent the spread of the COVID-19 virus, we cannot make any guarantees.
  • our Staff at Lyons Dental, are all symptom-free, have maintained social distancing the best they can, and truly feel that they have not been exposed to the virus. However, since we are in a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge.

In order to reduce the risk of spreading COVID-19, we have 2 additional forms, a 'Patient Screening Form' and a 'Curbside Check-in Form' that needs to be completed before we see you for your appointment. For the safety of our staff, other patients, and yourself, please answer these forms to the best of your knowledge.

We are taking every precaution in going the extra mile and doing all that we can. We are taking more time in performing thorough and detailed sterilization techniques between each patient. We will also be layered in a lot more PPE, as recommended by the States Guideline. We are adding in air purification and using high evacuation system to reduce aerosols. We are trying to make our office as safe as we can for your next dental appointment.

We will also be seeing far fewer patients at one time, and taking steps to prevent contact between our patients in any one area, and do our best to maintain social distancing too. Thank you for trusting us with your care, and we look forward to your visit.


, AGREE TO KNOWINGLY AND WILLINGLY HAVE DENTAL TREATMENT DURING THE COVID-19 PANDEMIC. Please acknowledge this letter by signing it, and giving us consent to treat and care for your dental health and wellness.

Patient Screening Form

General Information

Patient Screening

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
Are you/they having shortness of breath or other difficulties breathing?
Do you have a cough?
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Have you/they experienced recent loss of taste or smell?
Are you/they in contact with any confirmed COVID-19 positive patients?
Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.
Is your/their age over 60?
Do you/they have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?
Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)

Curbside Check-In

Curbside Check-In

We are adjusting to how patients come to the office during this COVID-19 Pandemic. When you arrive, please call our office to let us know that you are here. You can call us at (937) 428-2288 or text 1-864-507-5478.

We need to know the color and the make of your vehicle. We will be asking you to wear any kind of mask that provides facial coverage for your nose and mouth. It can be a regular mask, a bandana, a scarf. All accompanying visitors need to wait in the car, whether you are accompanying a minor or wheelchair bound patient. Only the 'patient' is allowed in, for treatment in the rooms. As we are going above and beyond to protect you, and your safety is our top priority, there will be an additional fee for PPE of $20. If there is a change with your dental insurance, please call and provide that information prior to appointment.


Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.