Medical & Dental History

Divine Dental Hygiene

Please correct the errors described below.
Seniors or Special Needs or Children

Insurance (only needs to be filled out for the adults, I will add it to the kids file if needed)

Covid-19 Symptoms and other Communicable Diseases

If you have any of these Covid-19 or other disease symptoms, you must cancel your appointment. Please confirm that you do not have any of these symptoms prior to this first appointment.

  • Cough or shortness of breath
  • Fever or chills in the last 24 hours
  • Loss of taste or smell
  • Feeling of unwell or fatigue
  • Sore throat
  • Nausea or vomiting
  • Undiagnosed rash, infection or break in the skin
  • Communicable infectious disease (flu, cold, measles, chicken pox, or tuberculosis)
  • Recent exposure to COVID-19, positive case exposure
  • Recent travel to areas where endemic diseases are present
  • Recent travel out of the country in the last two weeks, without Covid-19 PCR test upon return
  • Tested positive for Covid-19 in the past 14 days

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