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COVID-19 SCREENING FORM

Please fill out the mandated COVID-19 Screening Form below before your next appointment.

CHILDREN’S PATIENT FORM (1)

Patients Name*
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Address*
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Parent Name*
Best way to contact you:*
Please check any of the following that apply:*
Has your child ever had any of the following?*
Does your child have or have they ever had any of the following?*
Please check any of the following that apply:

For Parents

Dental Insurance

Parent Name ( required for under 18 years )*
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