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)?*

YesNo
OR
Are you currently experiencing symptoms of COVID such as a cough, fever, sore throat, shortness of breath or loss of sense of smell?*

YesNo
Who Signs?*

PatientNot the Patient
Signature

Clear
Patient Name*

First NameLast Name
Date*

DayMonthYear
Date
Should be Empty: