Due to the COVID 19 pandemic, we ask that you complete this form prior to arriving at our office. In order to safeguard our dental office, our patients and the rest of the community, we ask that you arrive wearing a face mask. We will provide a face mask for you if you do not have one. We also ask that you call upon arrival so you can be escorted to your treatment room. We ask if you are experiencing any symptoms related to COVID 19, that you call the office to reschedule.Name*Phone*Email* Have you traveled anywhere recently that are locations of disease outbreak?YesNoHave you been in contact with anyone who was/is sick?YesNoHave you attended any large group functions?YesNoHave you had any of the following symptoms within the last two weeks: fever, fatigue, dry cough, altered taste, altered smell, trouble breathing, productive cough, or muscle pain?YesNoHave you previously had the SARS-COV-2 virus (novel coronavirus)?YesNoDid you test positive and what test were you administered?Are you over the age of 65 and/or have preexisting health conditions related to the following: Diabetes, chronic lung disease or asthma, serious heart condition, immunocompromised, or chronic kidney or liver disease?YesNoIf you answered yes to question 6, we will ask that you consult with us.We thank you for your cooperation and we will contact you if we need further information. We can’t wait to see you! *Please consult your medical provider if you have any other symptoms that concern you. If you develop any of the following symptoms, seek emergency medical attention immediately: *trouble breathing, persistent pain or pressure in the chest, new confusion or inability to arouse, bluish lips or face*CAPTCHACommentsThis field is for validation purposes and should be left unchanged.