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Gallenito Dental Studio Covid 19 Prescreening Form

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Gallenito Dental Studio COVID-19 Prescreening form

Health

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Please answer the following questions to help us ensure the safety of our patients and staff.

Email*

Full Name*

Date of Birth*

Select date

Have you traveled outside of...*

Have you been in close conta...*

Have you experienced any of ...*

Description:Gallenito Dental Studio COVID-19 Prescreening Form

This form is designed to prescreen patients for COVID-19 symptoms before their dental appointment at Gallenito Dental Studio. The form includes questions about recent travel, exposure to COVID-19, and symptoms such as fever, cough, and difficulty breathing. By completing this form, patients can help ensure the safety of themselves, other patients, and staff at the dental studio. Gallenito Dental Studio is committed to following all recommended guidelines from health authorities to prevent the spread of COVID-19.

Full Name*

Date of Birth*

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Gender*

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Date of Birth*

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Gender*

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First Name*

Last Name*

Date of Birth*

Select date

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Full Name*

Phone Number*

Date of Birth*

Select date

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Patient's Full Name*

Patient's Date of Birth*

Patient's Address*

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Phone Number*

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