Safety Precautions

Covid Consent

Please Complete Before Your Visit

ADA&C Covid Consent Form

  • - Fever > 38°C
    - Cough
    - Sore Throat
    - Shortness of Breath
    - Difficulty Breathing
    - Flu-like Symptoms
    - Runny Nose
  • I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have the above listed emergency or urgent dental treatment completed during the COVID-19 pandemic.
  • Date Format: MM slash DD slash YYYY