COVID19 FORM | Dental Care Center Mazatlan - Dr. Beatriz Jaime Dr. Francisco Gavito

Welcome to Gavito-Jaime Dental Care Center

for your admission process, we ask that you complete this health form before going to your appointment. Thank you

PLEASE FILL THE INFORMATION

Name of patient *

Name of who fills out the form *

Relationship with the patient *

Phone (WhatsApp) *

Email *

Has the patient had a fever in the last 14/21 days?

Has the patient failed to breathe or experienced difficulty breathing?

Has the patient had a cough in the last 14 days?

Has the patient had or had stomach problems, headaches or fatigue?

Has the patient lost his sense of smell?

The patient has been in contact with people confirmed with COVID19?

Is the patient over 60 years old?

Does the patient have heart, kidney, diabetes, or autoimmune diseases?

Has the patient traveled in the last 14 days to regions affected by COVID19?

I verify that all the captured data is correct *

You agree that Gavito Jaime Dental Care Center will obtain your personal data in order to schedule a safe appointment

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