Dear Patients, Parents and/or Guardians,

Due to the COVID-19 pandemic, it has become necessary that we ask all parents/patients to complete the following questionnaire.
Please make sure to fill out this form before you come in for your appointment, but not sooner than 24h prior to it.

QUESTIONNAIRE

Has the patient or anyone in the patient's household recently had, or currently have, any of the following symptoms? (please check any/all that apply)
- Sore Throat
- Cough
- Fever of more than 100 degrees
- Persistent pain. pressure or tightness in the chest
- Feeling ill in any way

Yes

Has the patient or anyone in the patient's household, come into contact with anyone who may have tested positive for COVID-19 within the last 30 days?

Yes

Did you respond Yes to either of the above questions?

Yes - Please call our office now: 540-720-4178

No - Please continue to the next section of this form

IF YOU RESPONDED YES TO EXPOSURE OR ANY OF THE ABOVE SYMPTOMS PLEASE CALL US NOW:
540-720-4178

Please continue if you answered "No" to the previous question.

By clicking below, I acknowledge that there is always a risk when not social distancing. While exposure is unlikely due to all precautions taken, I accept this risk and consent to treatment today.

Responsible Party's Name

Responsible Party's Email

Responsible Party's Mobile Phone

Patient's Full Name

Today's Date

Is today's patient experiencing an oral emergency?

Yes

Please tell us about your car so we may find you more easily: Make/Model, Color & Plate #

Please call the office at 540-720-4178 or text 540-847-5874 to let us know you have arrived, and have submitted your health questionnaire. We will instruct you when to enter the office. Temperatures will be taken upon entry.

By submitting this form you confirm that all of the above questions have been answered truthfully.

By sharing this data, you authorize its use per our Terms of Use.

To withdraw or limit consent please contact us.