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ADA COVID Patient Screening Form

Beautiful Smiles Plantation

1368 N University Dr,,
Plantation, FL 33322
(954) 719-4382

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
ADA COVID Patient Screening Form( * mandatory to fill )
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

For testing, see the list of State and Territorial Health Department Websites for your specific area's information.

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