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COVID-19 Dental Treatment Consent Form
Please fill this form out prior to your appointment.
We still require our patients to wear a mask while in our reception area.
Thank you kindly!
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Email
*
Your email
Patient's name
*
Your answer
Please check any symptoms you are currently experiencing (unrelated to chronic conditions).
Cough
Fever/Chills
Sore Throat
Runny nose/Nasal Congestion
Loss of smell/taste
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In the last 10 days have you or anyone in your household tested positive for COVID-19?
*
Yes
No
Required
I verify the information I have provided on this form is truthful and accurate.
*
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/
YYYY
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