Patient Advisory and Acknowledgment - Waverley Oaks Dental
(781) 647-0022
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465 WAVERLEY OAKS ROAD
SUITE 208
WALTHAM, MA 02452
781.647.0022
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Patient Advisory and Acknowledgment
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Patient Advisory and Acknowledgment
Patient Advisory and Acknowledgment
Receiving Dental Treatment During the COVID-19 Pandemic
PATIENT INFORMATION
PATIENT / RESPONSIBLE PARTY
*
First
Last
EMAIL ADDRESS
*
TODAY'S DATE
*
Date Format: MM slash DD slash YYYY
PLEASE ANSWER “YES” OR “NO”, TO THE FOLLOWING QUESTIONS:
DO YOU HAVE A FEVER?
*
Yes
No
DO YOU HAVE ANY SHORTNESS OF BREATH?
*
Yes
No
DO YOU HAVE A DRY COUGH?
*
Yes
No
DO YOU HAVE A RUNNY NOSE?
*
Yes
No
DO YOU HAVE A SORE THROAT?
*
Yes
No
WITHIN THE LAST 14 DAYS, HAVE YOU TRAVELED TO ANY FOREIGN COUNTRY?
*
Yes
No
IF "YES" ON THE PREVIOUS QUESTION, WHERE?
SIGNATURE
*
CAPTCHA
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