Covid | Orthos Boutique Smiles

COVID PRE-SCREENING

This should be filled out by a patient’s legal guardian!

If you’re an adult patient or a minor filling this out for yourself, please continue. We’ll be notified to get further consent from your legal guardian.

If you’re under the age of 13, do not continue. Please contact our office.

Get Started:

Parent or legal guardian’s name

What is the patient's name?

Describe the car you will be driving so that we can find you once you check in

Have you, or anyone with you, traveled overseas in the last 14 days?

Have you, or anyone with you, traveled within the USA by air, bus, or train in the last 14 days?

Have you, or anyone with you, been tested for COVID-19 and are awaiting the results?

Have you, the patient, or any of your recent acquaintances tested positive for COVID-19 or any other diseases in the last 14 days?

Have you come into contact with anyone experiencing symptoms of COVID-19 in the last 14 days?

Have you, the patient, or anyone in your household or in close contact with you, experienced a persistent cough or shortness of breath in the last 14 days?

Have you, the patient, or anyone in your household or in close contact with you, had a fever in the last 14 days?

Is the patient older than 65?*

Do you have any chronic immune or systemic conditions?

Consent to Treatment

YES. I CONSENT TO TREATMENT

As with any illness, anyone can be exposed to COVID-19 at any time or place. We have always followed all recommended guidelines, laws and disinfection protocols in our office. Even with our careful attention, the chance remains that you could be exposed in our office, just as you might be anywhere. We’ve taken significant measures to keep you safe, however, it’s not always possible to maintain a constant distance between the patient, our office staff, and sometimes other patients.

Type Full Name

By signing the document above, and filling out this form, I confirm that I understand the questions presented to me and that I’ve answered all these questions honestly. I also understand that these answers may result in being asked to reschedule today’s appointment. I confirm that I am not a minor, am the legal guardian of this patient, or am an adult patient filling this out for themselves.

COVID PRE-SCREENING

This should be filled out by a patient’s legal guardian!

Get Started:

Copyright 2021 Orthos Boutique Smiles

Check-In