COVID-19 Patient Screening Form

Please correct the errors described below.

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.

Your information will be encrypted.