COVID-19 Dental Screening Form
For the safety of staff, patients and community, I have had to make the difficult decision to suspend all routine dental care until further notice.
If you have a dental complaint please complete and submit this COVID-19 Dental Screening Form. We will try to help you.
This method of screening is necessary to protect staff and to save very scarce protective equipment for the most serious cases.
Declaration required by Dentist's Indemnity Insurance
Please be aware of the severe limitations of providing advice and / or treatment and / or prescribing medication without a full dental examination. Due to the current circumstances we are unable to provide any further service or assistance at this time. Checking the question below and submitting this form will be taken as your acceptance and understanding of these limitations and your consent to same.
I understand these limitations and I consent to same
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service