Skip to content
Search for:
Home
About Us
About Dr. Ho
Our Staff
Office Tour
Services
Family & General Dentistry
Regular cleaning and Annual Dental Examination
Root Canal Therapy
Extraction
Dentures
Children Dentistry
Cosmetic Dentistry
Crowns & Bridges
Inlay/Onlay
Composite Fillings
Teeth Whitening
Porcelain Veneers
Emergency
Invisalign
Botox Cosmetic
Zoom! Whitening
Intraoral Scanner
Before and After
Testimonial
Contact Us
Survey
Home
/
Survey
Have you experienced any of the following symptoms of COVID-19 within the last 14 days? Cough, sore throat, shortness of breath, muscle pain, runny nose, sneezing, loss of smell with or without fever
Yes
No
Have you been in close contact or have been in isolation with a suspected or confirmed case of COVID-19 in the last 14 days?
Yes
No
Have you travelled internationally in the last 14 days?
Yes
No
Name
Date
I, verify that the answer I provided on this form to be truthful and honest. It is my responsibility to notify the office if any of the answer changes before my appointment
Yes
No
Send Message
New Patient Form
