Kirkwood

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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: 06/01/2023

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Progressive Dental Kirkwood

CORONA VIRUS SCREENING QUESTIONNAIRE PROGRESSIVE