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(949) 459-9300
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About Us
About the Doctors
Dr. Amir Larijani
Dr. Morvarid Madani
Meet Our Team
Amber C. Howard, RDH
Reza Larijani, MBA
Eddie Arreola, DA
Tamiko Williams, RDA
Office Tour
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Dental Bonding
Dental Crowns
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Patient Screening Consent Form
Patient Screening Consent Form
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Please enable JavaScript in your browser to complete this form.
Patient Screening Consent Form
I, knowingly and willingly Consent to have dental treatment completed during the COVID-19 pandemic and health crisis.
COVID-19 is highly transmissible and serious infection that may require hospitalization and could result in death.
First Name
*
Last Name
*
Phone
*
Fever or feverish over the past 14-21 days?
No
Yes
Shortness of Breath or difficulties breathing?
No
Yes
Dry Cough? Runny Nose? Sore Throat?
No
Yes
Flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
No
Yes
Recent loss of taste or smell?
No
Yes
In contact with any confirmed COVID-19 positive patients?
No
Yes
Are you over the age of 65?
No
Yes
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
No
Yes
Consent
*
I also verify that I have not traveled within or outside the United States in the past 14 days to any regions affected by COVID-19
Date
*
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Phone
Submit
Close Menu
Home
About Us
About the Doctors
Dr. Amir Larijani
Dr. Morvarid Madani
Meet Our Team
Amber C. Howard, RDH
Reza Larijani, MBA
Eddie Arreola, DA
Tamiko Williams, RDA
Office Tour
Dental FAQ
Financing
Services
Dental Implants
Dental Bonding
Dental Crowns
Dental Fillings
Emergency Dentist
Invisalign
Sedation Dentistry
Periodontics
Porcelain Veneers
Teeth Whitening
Tooth Extraction
Root Canal
Smile Gallery
Testimonials
Videos
22195 El Paseo #260
Rancho Santa Margarita, CA 92688
Call Us (949) 459-9300
Office Hours
Monday: 7am – 4pm
Tue-Thur: 8am – 5pm
Friday: 7am – 2pm
Sat-Sun – Closed
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