Commitment to Safety Form

At Corbin Family Dental Care, ensuring the safety of everyone in our office (including both patients and team members) is always a top priority. Before you arrive here for a scheduled appointment, please fill out the short form below and answer the questions as truthfully as possible.

Do you currently have a fever, or have you had one in the last two to three weeks?

Yes No

Are you currently experiencing shortness of breath or other breathing difficulties?

Yes No

Do you have a cough?

Yes No

Do you have fatigue, headaches, and/or gastrointestinal distress?

Yes No

Have you experienced any loss of your sense of taste and/or smell?

Yes No

Are you in close contact with anyone who has tested positive for COVID-19?

Yes No

Are you over 60 years of age?

Yes No

Do you have any of the following health conditions: heart disease, lung disease, kidney disease, diabetes, or an auto-immune disorder?

Yes No

Have you traveled to any states or areas heavily affected by COVID-19 and are under travel advisory by the state of Kentucky?

Yes No
Submit

Based on your answers, you may need to speak with one of our team members over the phone before we can proceed with an in-person visit. We will reach out to you directly if that is the case.

Please note that when arriving at the office, plan to stay where you are, contact us from your car, and let us know that you are outside first. We will then direct you when to come to the front door, where you will be granted entry and warmly greeted by our staff. We will also take your temperature at this time. Please see our commitment to safety for any further questions about what to expect during your appointment and how we are enhancing your safety. Thank you!