Covid19 Dental Cares

Thank you to complete this form prior to an appointment during the current sanitary context,
Regular patients and new patients are welcome. We need to prioritize and schedule according to this period.
We'll be in touch with you asap. Meanwhile , stay well & be safe . Thank you for your understanding.

In the event of symptoms related to Covid-19 for yourself or someone close to you, please cancel your appointment either directly by your Doctolib account or by email : drthierrymeyer@gmail.com

Your last appointment in our dental office *

Less than one year More than one year First time , I am a new patient

Patient at high risk category, including: diabetes, cardiovascular disease,
hypertension, lung diseases including moderate to severe asthma, being immunocompromised, having
active malignancy, or over age 65... You can have dental cares if your medical doctor agrees or after we chat together.

Your health *

I consider myself in a high risk category but I don't wish to report my dental cares anymore I consider myself not in a high risk category

By sending this form , I verify the information I have provided is truthful and accurate. If any change occurs, I will inform the dental office before my appointement *

I understand and I confirm

Covid19 - Health certificate before dental cares