COVID-19 Risk Assessment

Patient Name

Phone Number

Have you been fully vaccinated?

Have you had a fever, cough, shortness of breath, sore throat, any new loss of smell or taste, muscle pain, or flu-like symptoms in the past 14 days? OR Have you been near or had physical contact with anyone who has had these symptoms or has been diagnosed with COVID-19 in the past 14 days?

Yes

I agree to contact Greater Connecticut Oral & Dental Implant Surgery if I develop any of these symptoms within 14 days of my last visit to an OMS office.

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First Name

Last Name

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I agree to electronically sign and to create a legally binding contract between the other party and myself or the entity I am authorized to represent.