COVID-19 Questions

COVID-19 questions

Do any of the following questions apply to the person that is booking in for a dental appointment with Smile In Style?
Patient Name

First NameLast Name
Gender
If "Other" Please Specify
In the last 7 days
Have you or anyone in the household been diagnosed with Coronavirus (COVID-19)?
OR
Are you currently experiencing symptoms of COVID such as a cough, fever, sore throat, shortness of breath or loss of sense of smell?
Who Signs?
Signature
Patient Name

First NameLast Name
Date

DayMonthYear
Date
Should be Empty: