Mandatory Health Form

Please complete this mandatory form prior to any office visit.

"*" indicates required fields

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*
MM slash DD slash YYYY
Reset signature Signature locked. Reset to sign again
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.