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Covid 19

Orthodontics

Covid-19 Health statement

How are you feeling today?

First Name

Family name

E-mail

Date of your appointment

Tijdstip van uw afspraak

My body temperature is below 37.7 degrees

I have no symptoms and feel fine

I have not been in contact with a covid-19 patient in the last 14 days

Date

I hereby declare that this information is correct and complete

Thank you for your cooperation

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