COVID-19 Pandemic-Patient Disclosures

If you are seeking emergency dental treatment during this pandemic, please fill out the following:

COVID-19 Questionnaire – Bermuda Run Office

COVID-19 Questionnaire – Bermuda Run Office

Spanish COVID-19 Questionnaire – Bermuda Run Office

After you have completed the form, please make sure to press the Complete and Send button at the bottom to automatically send us your information. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.

COVID-19 Questionnaire – Kernersville Office

COVID-19 Questionnaire – Kernersville Office

Spanish COVID-19 Questionnaire – Kernersville Office

After you have completed the form, please make sure to press the Complete and Send button at the bottom to automatically send us your information. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.

These forms contain information we’ll need from you about COVID-19 and any possible conditions that may put you at greater risk, which we require before making any treatment decisions. It also explains the risks involved in seeking dental care during this pandemic.