Karl A Arakelian, DMD
For the health and safety of our community, declaration of illness is required. Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the COVID-19 signs.
Name
First Name
Last Name
Please state whether you've experienced/are experiencing the following
Yes
No
Fever
Cough
Shortness of Breath
Loss of taste or smell
Have you been in contact with people being infected, suspected or diagnosed with COVID-19?
Yes
No
Have you traveled in the past 14 days?
Yes
No
I acknowledge that the information I've given is accurate and complete.
Date
-
Month
-
Day
Year
Date
Signature
Submit
Should be Empty: