• COVID-19 SCREENING FORM ~ PLEASE CONFIRM ALL POINTS AND COMPLETE WITH FULL SIGNATURE

    If you have recently traveled anywhere, have any signs of cold or flu-like symptoms, or have been in contact with someone exhibiting symptoms, please self-isolate and do not visit the dental office for 14 days for precautionary reasons.
  • Date Format: MM slash DD slash YYYY
  • Fever > 37.5 C
    Cough
    Sore
    Shortness of breath
    Flu-like symptoms
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