Essence Dental Covid-19 Health Declaration

How are you feeling today?  Please complete this form no more than 48 hours before your scheduled appointment.

  • Fever

  • New onset of cough / Worsening chronic cough

  • Shortness of breath / Difficulty breathing

  • Sore throat / Difficulty swallowing

  • Decrease or loss of sense of taste or smell

  • Chills, headache, unexplained fatigue

  • Nausea, vomiting, diarrhea, abdominal pain

  • Muscle aches

  • Pink eye (conjunctivitis)

  • Runny nose / Nasal congestion

If you cannot submit this form, please call the office directly.