Covid-19 Screening and Disclosure/Consent

In order to reduce the risk of spreading COVID-19, we have asked you a number of “screening” questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid

in your answers.

11001 West 120th Ave, Suite 400, Broomfield Colorado, 80021

Ph. 720-263-6177 Email: Anesthesia@mountainda.com

©2019 by Mountain Dental Anesthesia.

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