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Name*
First Last
In the past 14 days, have you had any fever, difficulty breathing, cough, flu like symptoms, or loss of taste or smell?*
- Yes
- No

In the past 14 days, have you been exposed to any confirmed COVID-19 patients?*
- Yes
- No
Patients who are well, but who have a sick family member at home with COVID-19 should consider postponing elective treatment.
In the past 14 days, do have you traveled outside of the local area?*
- Yes
- No

In the past 14 days, have you tested positive for COVID-19?*
- Yes
- No
What date was the test?
Date Format: MM slash DD slash YYYY
Have you been symptom free for 24 hours?*
- Yes
- No

Are you over the age of 60?*
- Yes
- No
Do you have heart disease, lung disease, kidney disease, diabetes, autoimmune disorders, dementia, or are you pregnant?*
- Yes
- No

Your Contact Information
Email
Phone Number*
Date of Birth*
Date Format: MM slash DD slash YYYY

Preferred Appointment Dates
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Preferred Time Date #1
Preferred Date #2
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Office Hours

Monday 9:00 am – 6:00 pm
Tuesday 11:00 am – 7:00 pm
Wednesday 8:00 am – 5:00 pm
Thursday 8:00 am – 5:00 pm
Every other Friday 8:00 am – 2 pm
Saturday Closed
Sunday Closed

About Us

My Family Dentistry in Powell TN puts “comfortable dentistry” at the heart of our practice. Dr. Wesley Mullins and his team provide compassionate care, experience, a gentle touch, and excellent dentistry that will make you want to be a patient of My Family Dentistry.

Location

My Family Dentistry
7714 Conner Road #102
Powell, TN 37849

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