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(949) 661-5841
Patient Screening Consent Form
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Patient Screening Consent Form
I, knowingly and willingly Consent to have dental treatment completed during the COVID-19 pandemic and health crisis.
COVID-19 is highly transmissible and serious infection that may require hospitalization and could result in death.
First Name
*
Last Name
*
Phone
*
Fever or feverish over the past 14-21 days?
No
Yes
Shortness of Breath or difficulties breathing?
No
Yes
Dry Cough? Runny Nose? Sore Throat?
No
Yes
Flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
No
Yes
Recent loss of taste or smell?
No
Yes
In contact with any confirmed COVID-19 positive patients?
No
Yes
Are you over the age of 65?
No
Yes
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
No
Yes
Consent
*
I also verify that I have not traveled within or outside the United States in the past 14 days to any regions affected by COVID-19
Patient Signature
*
Clear Signature
Date
*
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