FIRST AND LAST NAME .....................................................................................................................................…………….......

ADDRESS …........................................................................................................................................................

CONTACT INFO …........................................................................................................................................................

  (tel. / e-mail)                   

YEAR OF BIRTH   ….................

 PLEASE ANSWER THE FOLLOWING QUESTIONS BY YES OR NO.

  (All you will complete is confidential, and for safety reasons only).

•             Have you or anyone close to you diagnosed with COVID-19?

•             Have you experienced or anyone close to you, fever, dry or etching throat, lack of taste or smell, headaches   or general discomfort the last 15 days?                         

•             Have you, or anyone close to you, travelled abroad the last 15 days? 

•             Have you any allergies to anesthetics or medication?

•             Are you under any medication now? 

•             Is there anything from your medical history you’d like to discuss with your Dentist?

•             Do you agree with your contact info use, for your treatment’s best programming ? 

                                                                                                       ……........................................

                                                                                                             (Signature and date)

PLEASE NOTE : All medical records and x-rays you provide, will be returned by the end of your treatment.