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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.

8683 Lincoln Ave #130, Lone Tree, CO 80124

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

©2019 by Mountain Dental Anesthesia.

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