INSTRUCTIONS FOR USE: This form is to be filled out twice: 1) Please fill out this form 1-2 days BEFORE your appointment and 2) in our office on the SAME DAY of your appointment.
If you answered No to the above question, you are done completing the Yes/No portion of this form. If you answered Yes to the above quesion, please continue on to the next question.
I agree to notify the dental practice if within 14 days I become ill with COVID-19 symptoms or test positive for COVID-19. I understand the dental practice has a legal and ethical obligation to inform me if a staff person I had contact with tested positive for COVID-19 within 14 days.