COVID-19 Patient Screening Form

Positive responses to any of these would likely indicate rescheduling your appointment or a further discussion with the dentist before proceeding with dental treatment.

By my signature below, I certify the information I provided on this form is true and correct to the best of my knowledge. I also acknowledge that there is a risk to spread and/or contract COVID-19 in a healthcare setting.

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.