Please print and bring this form in with you at time of visit. If you do answer yes to the below quewstions, or have any concerns or questions call us prior to your visit at (801) 446-4668.

Patient Full Name _______________________________________________

Preferred Name _________________________________________________

(circle applicable answers)
Do you have a fever or have you felt hot or feverish recently (14-21 days)? 
Yes / No

Are you having shortness of breath or other difficulties breathing?*
Yes / No

Do you have a cough?*
Yes / No

Are you in contact with any confirmed COVID-19 positive patients?*
Yes / No

Have you  experienced recent loss or taste of smell?*
Yes / No

Patients who are well but have a sick family member at home with COVID-19 should consider postponing elective treatment

Do you have heart disease, lung disease, kidney disease, diabetes or any other auto-immune disorder(s)?
Yes / No

Have you traveled in the past 14 days to any regions affected by COVID-19?*
Yes / No

I knowlingly and willingly consent to dental treatment at Willden Family Dental by Dr. Ryan Willden and any designated associates and employees during the COVID-19 Pandemic, I understand that Dr. Ryan Willden is following the CDC guidelines. Risk of transmission: I understand that due to the frequency of visits for patient care that I have an elevated risk of contracting the virus. I am unaware of being a possible carrier or infected: I condirm that I have not tested positive for COVID-19 *

Signature _________________________________________________ Date ___________________