COVID 19 Intake Form Patient Details

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COVID 19 Intake Form MEDICAL HISTORY UPDATE

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COVID 19 Intake Form COVID-19 SCREENING

Coronavirus Disease 2019 (COVID-19) has been reported in every state and country around the world. In order to protect you and others, we are asking about symptoms and exposure to COVID-19. Patient and staff health is our priority please answer these questions so we can do our part to ensure your safety and that of our patients and staff.

 

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  •  Chills or shaking
  •  Muscle aches and pains
  •  New loss of taste or smell
  •  Vomiting or diarrhea
  •  Sore throat
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COVID 19 Intake Form AUTHORIZATIONS

Please note the following changes in the way we are managing patient flow in our office:

Our reception area is closed. We kindly request that you wait in your car until we call you to let you know it is safe to enter our office.

Masks are required in the building. Once our office is ready to see you, we ask that you wear a mask as you enter our building. When you enter our office, we will take your temperature at the door and provide you with hand sanitizer. If your temperature is over 100 degrees, you will be asked to go home and contact your doctor. 

Payment is expected at the time of service (via credit card, personal check, or cash) unless other arrangements are made prior to your visit. This includes treatments that may be covered by your dental insurance. If you have any questions about treatment costs, please call our office prior to your appointment.

If an appointment is canceled due to illness, there will be no charge for the missed appointment. However, failure to show up for an appointment for any other reason without 24 hours notice will result in a missed appointment fee of $50 per hour. Due to scheduling restrictions, we may not be able to reschedule missed appointments for several weeks.

We appreciate your understanding and cooperation. 

I hereby affirm that the information in this form is accurate to the best of my knowledge. I understand that if any new symptoms arise prior to my visit, I will inform the office as soon as possible. I also understand that payment will be expected at the time of service, unless other arrangements are made prior to my visit.

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