screening - Duluth MN cosmetic dentist

cosmetic
general
reconstructive
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cosmetic
general
reconstructive
sedation

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new patients

about
new patients

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patient screening

First Name

Middle Initial

Last Name

Nickname

Do you have a fever or have you experienced a fever in the past 14 days?

Yes No

Are you taking any fever reducing medications such as Aspirin, Tylenol, or Ibuprofen?

Yes No

Have you experienced recent onset of respiratory problems, such as a cough or difficulty breathing, within the past 14 days?

Yes No

Have you experienced recent loss of taste or smell?

Yes No

Have you traveled inside or outside of the country within the last 14 days?

Yes No

Have you come into contact with a person with confirmed COVID-19 infection within the past 14 days?

Yes No

Have you received a COVID-19 vaccination?

Update on Information

By checking this box you are agreeing to contact us within 24 hours before your scheduled appointment if there are any changes to the above answered questions.

REQUEST AN APPOINTMENT

2200 London Road
Duluth, MN 55812

(218) 728-4272

MONDAY – THURSDAY
8:00 am – 5:00 pm

2200 London Road
Duluth, MN 55812

(218) 728-4272

Hours:
MONDAY – THURSDAY
8:00 am – 5:00 pm

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patient screening

2200 London RoadDuluth, MN 55812

2200 London Road
Duluth, MN 55812