Fallbrook Family Dentistry

575 Fallbrook Blvd 107, Lincoln, NE 68521

| (402) 467-0007

COVID-19 Wellness Form

Please know that our office is following all recommended guidance from public health authorities, including best practices for hygiene, infection control and dental professional team health. We feel confident in our ability to continue seeing patients and providing dental care according to the Tradition of Quality Care that you have come to expect and deserve.

Due to the current situation with COVID-19 we are asking each patient to answer a few questions to ensure the health and safety of our patients and team members.

Have you previously been diagnosed with COVID-19, or do you think you’ve had/have COVID-19?
Do you currently have, or have you experienced any of the following symptoms in the past 21 days?
  • Fever
  • Dry Cough
  • Shortness of breath
  • Pain, pressure, or chest tightness
In the past 14 days have you been in contact with anyone who has tested positive for COVID-19?