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Your Name
E-Mail
Are you a patient of Record?
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COVID 19 Questionaire
Due to the COVID 19 Pandemic please answer these questions. You may choose more than one.
I or someone I am in close contact with has recently traveled to a country with large outbreaks of COVID-19 ?
I or a member of my household has/had a cough, fever, and/or flu-like symptoms in the past 14 days?
I do not have any symptoms.
Date of Birth
Appointment Type
New Patient Appointment
Limited Exam/Problem
Regular Cleaning
Restorative/Fillings
Crown and Bridge
Implants
All-on-4® Implant Consult
Denture Adjustment
Denture Consultation
Whitening
Account#
Contact Number
Appointment Date
Appointment Time
8:45 AM
11:30 AM
1:45 PM
2:45 PM
Comments/Notes
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