JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
At Kamatovic Orthodontics we wish to keep you, your family, and ours safe. Please answer the following questions honestly and to the best of your knowledge.
The Ministry of Health requires us to ask these questions at every appointment. Thank you.
Sign in to Google
to save your progress.
Learn more
* Required
Patient's LAST NAME,
*
Your answer
Patient's FIRST NAME
*
Your answer
Date of your Kamatovic Ortho Appointment
*
MM
/
DD
/
YYYY
Please review the following:
*
GOOD☺I answer NO to all the COVID-19 Screening questions and I accept all the COVID-19 risks
BAD ☹ I have issues with one or more of above. Please call (905) 356-7919 to reschedule your appointment and contact Public Health Niagara for further guidance.
Form completed by:
*
(patient or guardian)
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
Forms
This content is neither created nor endorsed by Google.
Report Abuse
Terms of Service
Privacy Policy