Name*

First name Name

I confirm my presence for the appointment*

Date of appointment*

I have an appointment with Dr.*

Appointment time*

:

The accompanying person remains in the car*

I come with my mask*

I only take my health card and a means of payment*

I come without a coat*

I confirm my arrival in front of the cabinet door*

E-mail*

Have you had at least 2 of the flu-like symptoms in the last 14 days?

Are you waiting for the laboratory results for a covid-19 test?*

Have you tested positive for covid 19*

Have you been asked to go into isolation in the last 14 days?*

Have you been in close contact with a person infected with covid 19 in the last 14 days?*

Can you confirm that you are aware of the 5 precautions rule*

The waiting room and toilets are closed for health reasons*

I did my mouthwash as prescribed on my prescription the day before and before coming to my appointment, I bring my mouthwash with me*

Signature*

RGPD*

I accept the privacy policy.

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