Patient Screening During COVID Pandemic

 To ensure the safe care of both our team and patients, including you, we kindly ask that you fill out the following form prior to your visit today. Thank you for your understanding.

Have you had a recent onset of the following symptoms within the past 10 days? (Check all that apply)
Have you been within 6ft without proper PPE of anyone who has tested positive for the Corona Virus within the past 14 days?
Have you had a positive COVID19 test within the last 9 days?

By checking the box below, I acknowledge that I am not currently ill to the best of my knowledge and fully understand that by going out in public, including Madison No Fear Dentistry, I could be exposing myself to the COVID-19 Virus. I further understand that Madison No Fear Dentistry is following all ADA and CDC protocols to protect its patients and employee's.