COVID-19 DENTAL APPOINTMENT PRESCREENING FORM2020-06-05T12:58:38-04:00
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height: auto; } .form-matrix-row-headers { width: 100%; word-break: break-all; min-width: 80px; } .form-collapse-table, .form-header-group { margin: 0; } .form-collapse-table { height: 100%; display: inline-block; width: 100%; } .form-collapse-hidden { display: none !important; } .form-input { width: 100%; } .form-label { width: 100% !important; } .form-label-left, .form-label-right { display: block; float: none; text-align: left; width: auto!important; } .form-line, .form-line.form-line-column { padding: 2% 5%; -moz-box-sizing: border-box; -webkit-box-sizing: border-box; box-sizing: border-box; } input[type=text], input[type=email], input[type=tel], textarea { width: 100%; -moz-box-sizing: border-box; -webkit-box-sizing: border-box; box-sizing: border-box; max-width: initial !important; } .form-radio-other-input, .form-checkbox-other-input { max-width: 55% !important; } .form-dropdown, .form-textarea, .form-textbox { width: 100%!important; -moz-box-sizing: border-box; -webkit-box-sizing: border-box; box-sizing: border-box; } .form-input, .form-input-wide, .form-textarea, .form-textbox, .form-dropdown { max-width: initial!important; } .form-checkbox-item:not(#foo), .form-radio-item:not(#foo) { width: 100%; } .form-address-city, .form-address-line, .form-address-postal, .form-address-state, .form-address-table, .form-address-table .form-sub-label-container, .form-address-table select, .form-input { width: 100%; } div.form-header-group { padding: 24px 0px !important; margin: 0 12px 2% !important; margin-left: 5%!important; margin-right: 5%!important; -moz-box-sizing: border-box; -webkit-box-sizing: border-box; box-sizing: border-box; } div.form-header-group.hasImage img { max-width: 100%; } [data-type="control_button"] { margin-bottom: 0 !important; } [data-type=control_fullname] .form-sub-label-container { width: 48%; } [data-type=control_fullname] .form-sub-label-container:first-child { margin-right: 4%; } [data-type=control_phone] .form-sub-label-container { width: 65%; margin-right: 0; margin-left: 0; float: left; } [data-type=control_phone] .form-sub-label-container:first-child { width: 31%; margin-right: 4%; } [data-type=control_datetime] .allowTime-container { width: 100%; } [data-type=control_datetime] .allowTime-container .form-sub-label-container { width: 24%!important; margin-left: 6%; margin-right: 0; } [data-type=control_datetime] .allowTime-container .form-sub-label-container:first-child { margin-left: 0; } [data-type=control_datetime] span + span + span > span:first-child { display: block; width: 100% !important; } [data-type=control_birthdate] .form-sub-label-container, [data-type=control_time] .form-sub-label-container { width: 27.3%!important; margin-right: 6% !important; } [data-type=control_time] .form-sub-label-container:last-child { width: 33.3%!important; margin-right: 0 !important; } .form-pagebreak-back-container, .form-pagebreak-next-container { min-height: 1px; width: 50% !important; } .form-pagebreak-back, .form-pagebreak-next, .form-product-item.hover-product-item { width: 100%; } .form-pagebreak-back-container { padding: 0; text-align: right; } .form-pagebreak-next-container { padding: 0; text-align: left; } .form-pagebreak { margin: 0 auto; } .form-buttons-wrapper { margin: 0!important; margin-left: 0!important; } .form-buttons-wrapper button { width: 100%; } .form-buttons-wrapper .form-submit-print { margin: 0 !important; } table { width: 100%!important; max-width: initial!important; } table td + td { padding-left: 3%; } .form-checkbox-item, .form-radio-item { white-space: normal!important; } .form-checkbox-item input, .form-radio-item input { width: auto; } .form-collapse-table { margin: 0 5%; display: block; zoom: 1; width: auto; } .form-collapse-table:before, .form-collapse-table:after { display: table; content: ''; line-height: 0; } .form-collapse-table:after { clear: both; } .fb-like-box { width: 98% !important; } .form-error-message { clear: both; bottom: -10px; } .date-separate, .phone-separate { display: none; } .custom-field-frame, .direct-embed-widgets, .signature-pad-wrapper { width: 100% !important; 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} .form-all { position: relative; } .form-all:before { content: ""; background-image: url("https://www.jotform.com/uploads/Storey_Seth/form_files/JOY-DENTISTRYada-1200x661.5ed93c628cae08.25059739.png"); display: inline-block; height: 165px; position: absolute; background-size: 300px 165px; background-repeat: no-repeat; width: 100%; } .form-all { margin-top: 175px !important; } .form-all:before { top: -175px; background-position: top center; } .ie-8 .form-all:before { display: none; } .ie-8 { margin-top: auto; margin-top: initial; } /*PREFERENCES STYLE*//*__INSPECT_SEPERATOR__*/ .form-label.form-label-auto { display : inline-block; float : left; text-align : left; } /* Injected CSS Code */
  • COVID-19 DENTAL APPOINTMENT PRESCREENING FORM

    Please complete and submit the form below.

  • Wellness Disclosure

  • COVID-19 Exposure

  • High-Risk Factors

  • 0/500
  • Informed Consent For

    COVID-19 Protocols

  • All patients entering a JOY Dentistry facility will need to review and consent to the following consultation terms

  • 1. I do hereby attest that the information I provided in this form is true and correct.

    2. I consent to have my temperature taken before entering the JOY Family Dentistry Facility.

    3. I agree to wearing a face mask that covers both my mouth and nose at all times in both public and clinical areas until otherwise instructed by our staff during the procedure.

    4. I consent to utilize JOY Family Dentistry’s hand sanitizer upon entrance and exiting.

    5. I will pay with a pre-filled out check or a credit card as forms of payment.

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