Addresses:
Danbury
129 Park Ave
Danbury, CT 06810

Phone:
(203) 790-0183

New Milford
487 Danbury Rd Bldg A
New Milford, CT 06776

Phone:
(860) 355-4146

Hours:
Mon–Fri: 8:00 AM–5:00 PM
Sat: 8:00 AM–1:00 PM

COVID-19 Risk Assessment

Patient Name

Phone Number

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?

Yes

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

Have you traveled out of southwest Connecticut in the last 14 days?

Yes

If yes, where have you traveled?

Have you been in contact with anyone who has traveled to southwest Connecticut from somewhere else?

Yes

If yes, from where?

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.