Family Orthodontics Patient Wellness Screening
To our orthodontic family and friends, thank you for your support and patience during the COVID-19 pandemic. We aim to resume orthodontic care in the safest possible way for both patients and staff. Part of that initiative includes the attached Wellness Screening that we request is returned prior to EACH APPOINTMENT. Please call/text (860-365-9021) or email the office (info@ctsmile.com) if you have any questions.
Your Name *
Patient name *
In the last 14 days, has the patient (or any member of the household) had any of the following? *
Yes
No
Fever (over 99.6 degrees F)
Coughing
Shortness of Breath
Difficulty Breathing
Persistent pain, pressure or tightness in chest
Traveled to a restricted state?
Recent loss of taste or smell?
Has the patient, a family member, or close contact had either of the following occur in the past 14 days? *
Yes
No
Diagnosis of COVID-19 infection, or any other communicable disease
Waiting on results of test for COVID-19 infection
If Yes, please explain and include test results if applicable. (If doesn't apply, write NA)
Has the patient been exposed to a known covid positive individual less than 6 feet away from them, for longer than 15 minutes, and without a mask?
Clear selection
Has the patient been specifically asked to quarantine from school or work?
Clear selection
If the answer is yes to any of the previous questions, I understand I may be asked to reschedule this upcoming appointment and should contact the office to discuss. *
In light of Covid-19, we understand scheduling needs may have changed. Please tell us which day of the work week would be most desired for physical appointments? *
Submit
Never submit passwords through Google Forms.
This form was created inside of Family Orthodontics. Report Abuse