Upcoming Appointment Patient Form | Smiles In The Gardens Dentistry

Have you been experiencing a fever or flu like symptoms?

Yes No

Have you had a persistent cough or shortness of breath?

Yes No

Have you been around anyone who has been sick?

Yes No

Have you tested positive for Covid-19?

Yes No

Because you checked yes, we are going to ask you to reschedule at this time.

If you answered no to the above questions please check here to confirm your upcoming appointment:

Yes, this is correct No, I would like to reschedule

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