Pre-Dental Visit Questionnaire
Due to the COVID-19 pandemic, it has become necessary that we ask the following questions. You will receive a confirmation message once it is completed. Please complete this form within 24 hours of your appointment and notify our office if there are any changes.
Appointment Date *
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Patient First Name(s) *
Patient Last Name *
Patient Date of Birth (if completing form for more than one child, enter date of birth of oldest) *
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DD
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YYYY
In the past 14 days, have you or your child tested positive for or been exposed to someone who has tested positive for COVID-19? *
If answered Yes to question above, please explain AND call our office for clearance on your appointment:
Is your child experiencing one or more of the following symptoms: cough, congestion, runny nose, loss of taste or smell, sore throat, body aches, vomiting or diarrhea? *
If answered Yes to question above, please explain AND call our office for clearance on your appointment:
In the past 10 days, has your child participated in any activity that has not adhered to CDC health and safety guidelines for social distancing and mask-wearing? *
If answered Yes to question above, please explain AND call our office for clearance on your appointment:
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