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Covid19 Questionnaire

This form is to be completed by patients prior to their dental appointment to ensure the safety of all patients and staff.

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Patient Information

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Description:Assess your risk of COVID-19 before visiting the dental clinic with this questionnaire. Answer questions about your symptoms, recent travel, and exposure to the virus. This form will help dental clinics to ensure the safety of their staff and patients.

Protect yourself and others from COVID-19 by completing this dental questionnaire before your visit to the clinic. The form asks questions about your symptoms, recent travel, and exposure to the virus. By answering these questions, you can help dental clinics to assess your risk of COVID-19 and take appropriate precautions to keep their staff and patients safe. This questionnaire is an essential tool for dental clinics to ensure that they are following the best practices for preventing the spread of COVID-19. By completing this form, you can help to protect yourself and others from the virus.

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Date of Birth*

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