COVID-19 Patient Forms

Please download COVID-19 forms and complete electronically.
When finished, you may submit them to us via email at

Patient Consent Form COVID19 Pandemic
Patient Disclosures COVID19 Pandemic

COVID-19 Information for Patients

Maintaining the health and safety of our patients and staff has always been the top priority for us at Cyndi Chen DDS ever since we first opened in 2004, and is especially important to us now during the current COVID-19 pandemic. In response to COVID-19, we have developed plans and new protocols to build upon our existing infection control procedures to keep us all safe. As always, we follow recommendations from the American Dental Association (ADA), the U.S. Centers for Disease Control and Prevention (CDC), and the Occupational Safety and Health Administration (OSHA), to ensure that we are up-to-date on any new rulings or guidance that may be issued.

The following is our new procedure for patients coming to visit our clinic. We ask that you take the time to read and understand our new rules, as they will be updated as new information and recommendations arise. We look forward to serving you and thank you for your helping us to keep you and our staff healthy and safe.

New Visit Procedures:

1. Prior to your appointment
Please fill out these patient self-screening and consent forms and return to us via email (

2. When coming to your appointment, we ask that all patients:
Bring and wear a mask.
Bring a zip-lock bag to carry the mask when not in use.
Bring their own pen.
Bring eye protection (if available).
We ask that all other personal belongings be left at home.

3. When you are inside our office
If not receiving treatment, please wear your mask at all times.
Once you have finished treatment, please put your mask back on.

4. To promote social-distancing:
Our waiting room and child play area are closed. Patients will be asked to wait in their vehicle
We ask that patients attend their visits on their own. Minors may be accompanied by one parent or guardian. All others will be asked to remain outside the clinic.
Within the clinic, patients are asked to maintain 6 feet between themselves and others whenever possible.

5. When arriving to your appointment:
Please plan to arrive at least 5 minutes before your appointment time.
Upon your arrival, please remain in your vehicle. Call our office at (408) 998-8886 to let us know that you have arrived. We will conduct a short phone patient health screen to verify that you are in good health.
We will call you when we are ready to see you. Until then, please stay in your vehicle.
When we are ready to see you, we will meet you at the front door to perform a temperature check, provide you with shoe covers, and take you to the operatory.

At the operatory and before your procedure, we ask that all patients:
Wash their hands for 20 seconds with soap and water.
Rinse their mouths with antimicrobial mouthwash.



5150 Graves Avenue, Building 6,
San Jose, CA 95129
Phone: (408) 998-8886