Mandatory Health Form

Please complete this mandatory form prior to any office visit.

Are you exhibiting symptoms of acute respiratory illness (fever, cough, shortness of breath, etc.)?*
Have you had close contact with a laboratory-confirmed COVID-19 case?*
Have you had contact or been in close contact with someone hospitalized with acute lower respiratory illness of unknown origin?*
Do you have a history of travel to or from an affected geographic area with widespread community transmission of COVID-19?*
Do you have a history of international travel, or have you been on a cruise in the past 4 weeks?*
Are you immunocompromised?*
Name*
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This field is for validation purposes and should be left unchanged.

We’re transforming lives in Austin, one smile at a time. Contact our dental office today at 512-448-3131 to reserve your appointment with Dr. Van Wicklen, and experience customized care for a truly fantastic smile.