Use this form to screen patients before their appointment and when they arrive for their appointment.
Who answered: PatientOther (specify)
Contact Method: PhoneEmailOther (Specify)
Identify yourself and explain the purpose of the call, which is to determine whether there are any special considerations for their dental appointment. Have the patient answer the following questions.
Please read the patient acknowledgement below, and initial or sign in all areas indicated.
checked * I verify the information I have provided on this form is truthful and complete. I knowingly and willingly consent to have surgical/dental treatment completed during the COVID-19 pandemic. 我確認以上信息的真實性和完整性，並同意在新冠病毒大流行期間接受牙醫治療。
Print Your Name*: Date*: