Receiving Dental Treatment During the COVID-19 Pandemic
Dear Patient:
You have come to our office today for a routine dental evaluation and/or treatment that will be done during the COVID19 pandemic. Please be advised of the following:
In order to reduce the risk of spreading COVID-19, we have asked you a number of “screening” questions bellow. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.