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PATIENT ACKNOWLEDGEMENT:
COVID-19 PANDEMIC DENTAL RISK

Please read the patient acknowledgement below, and initial or sign in all areas indicated

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I verify the information I have provided on this form is truthful and complete. I knowingly and willingly consent to have dental treatment completed during the COVID- 19 pandemic.


PATIENT SCREENING FORM


SCREENING QUESTIONS

**If you answered NO, please complete Q4 and Q5.


PLEASE COMPLETE Q4 AND Q5 ONLY IF YOU ARE NOT FULLY VACCINATED