We Require This Form To Be Completed Prior To Your Next Appointment!

If you answer yes to any of the following questions, we ask that you contact us immediately to reschedule your appointment as you will not be permitted into the clinic at this time.

All patients are required to review and submit a patient consent form prior to coming in for their next dental appointment.

PLEASE COMPLETE THE PATIENT CONSENT FORM BELOW:

* Indicates Required

CMOH Order 05-2020 legally obligates any person who has the following cough, fever, shortness of breath, runny nose, or sore throat (that is not related to a pre-existing illness or health condition) to be in isolation (quarantine) for 10 days from the start of symptoms, or until symptoms resolve, whichever takes longer. If they are exhibiting any of these symptoms, it is suggested they complete the COVID-19 Self-Assessment online tool to determine if they should be tested.

    *Patient First & Last Name:

    *Patient E-mail:

    SIGNATURE OF PATIENT

    Date Signed

    Thank you from the Team at Dimension Dentistry!

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