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COVID-19 PATIENT INTAKEadmin2020-10-27T13:49:33+00:00

Covid-19 Intake & Release

Step 1 of 3

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  • Please read the patient acknowledgement below, and initial or sign in all areas indicated.

  • (initial)
  • (initial)
  • (initial)
  • (initial)
  • (initial)
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  • MM slash DD slash YYYY
  • (initial)
  • (initial)
  • I verify the information I have provided on this form is truthful and complete. I knowingly and willingly consent to have emergency dental treatment completed during the COVID-19 pandemic.
  • MM slash DD slash YYYY
  • PATIENT SCREENING FORM
  • Use this form to screen patients before their appointment and when they arrive for their appointment.

  • MM slash DD slash YYYY

  • *For Office Use Only Below*

CONTACT INFORMATION

  • 5400 Tecumseh Rd, Windsor, ON N8T 1C7
  • 519.945.2337

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