Progressive Dental Kirkwood CORONA VIRUS SCREENING QUESTIONNAIRE PROGRESSIVE Name* First Last Date Of Birth* Month Day Year Do you have any COVID or flu-like symptoms?* YES NO Have you been in contact with anyone who has tested positive for COVID?* YES NO Patients who are well but who have a sick family member at home with COVID-19 should consider postponing/rescheduling treatment. Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with dental treatment.NA*NA I agree to above mentioned consent.Signature of Patient or Legal Guardian*Today's Date: 10/10/2024HiddenUsernameThis is a hidden field HiddenConsent TextNAHiddenHideAgeThis is a hidden field
