TeleDENTUS

The address provided is outside the boundary of TeleDENTUS. Please try a different address.

Missing information. Please fill out required information.

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

Patient Name

Have you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)

No answer

Yes

Have you tested for COVID-19?

No answer

I am awaiting results from a COVID-19 test.

I have not taken a COVID-19 test

Yes

Have you been in close proximity with someone who tested positive for COVID-19 or has symptoms related to COVID-19?

No answer

Yes

HIPAA ACKNOWLEDGEMENT Please be aware that this is a secure email network under HIPAA guidelines. Do not submit any personal or private information unless you are authorized and have voluntarily consented to do so. We are not liable for any HIPAA violations. Understand that if you email us, you are agreeing to the use of this secure method and understand that all replies will be sent by standard (unsecured) email, which you are hereby authorizing. By checking this box you hereby agree to hold the requested Dental Office, including its doctors and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties. By selecting yes, I acknowledge my understanding of the HIPAA Policy and agree with its contents.

No answer

Yes

Email Address

Attachment files size reached limit of 8Mb.

Missing information. Please fill out required information.