• 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 answer NO please complete Q4 and QS
  • Q2. Do you have any of the following symptoms?

  • PLEASE COMPLETE Q4 and QS ONLY IF YOU ARE NOT FULLY VACCINATED