COVID-19 Screening Questionnaire

Sein H. Siao, DMD & Associates, PC

Please correct the errors described below.

SCREENING QUESTIONNAIRE:

YOU ARE RECEIVING DENTAL CARE DURING THE EVENTS OF A COVID-19 NATIONAL EMERGENCY. PLEASE BE ADVISED THAT THERE MAY BE RISKS IN BEING IN THE PROXIMITY OF DENTISTS, PATIENTS, OR STAFF. WE ARE TAKING PRECAUTIONS TO LIMIT THE SPREAD OF DISEASE, YET THERE IS STILL A POSSIBILITY OF TRANSMISSION.

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.

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