Please complete this form for the patient as well as any parent, guardian, or caretaker needing to accompany the patient in the dental office within 24 hours of your upcoming appointment. EACH patient needs to have a separate form completed.
This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID‐19 virus.
Our goal is to provide a safe environment for our patients and staff, and to advance the safety of our local community. This document provides information we ask you to acknowledge and understand regarding the COVID‐19 virus.