Dr. Simons Orthodontics Wellness Form
Please fill out this form and submit it a day prior or the morning of your appointment. For simplification, "the patient" may refer to you or to your child.
What is the patient's name? *
Please confirm the cell phone number to best reach you. *
Has the patient experienced any of these symptoms in the past 14 days? *
Required
Has the patient participated in any large gatherings (of more than 10 attendees) or gatherings of people you didn't know in the last 14 days? *
Has the patient or a member of his/her household traveled outside of the country in the past 14 days? *
Has the patient been tested for COVID-19 with a positive result? *
Has the patient or a member of his/her household been sick or had a fever within the last 14 days? *
Has the patient recently traveled to an area with known local spread of COVID-19? *
Has the patient come into close contact (within 6 feet) with someone who has had a laboratory-confirmed COVID-19 diagnosis in the past 14 days?
Clear selection
If the answer is YES to any of these questions or any answer changes prior to the scheduled appointment or any of these symptoms mentioned deem it necessary to do so, I agree to notify Dr. Simons' office by contacting us at 504-887-8480 as soon as possible in order to keep her staff and other patients safe by rescheduling the appointment. *
Treatment Consent: Dear patient, you have come to our office today for a routine dental evaluation and/or treatment that will be done during the Covid-19 pandemic. Please be advised on the following: While our office complies with State Health department and CDC guidelines to prevent the spread of Covid-19 virus we cannot make any guarantees. Our staff are symptom free and to the best of their knowledge have not been exposed to the Covid-19 virus. However since we are a place of public accommodation other patient could be infected with or without their knowledge. In order to reduce the risk of spreading Covid-19 we have asked you a number of "screening questions" above. For the safety of our staff, patients, and yourself please be truthful and candid in your answers. Clicking "YES" to the following question indicates that the risks involved in making an appointment are understood and accepted, as well as consent is given for treatment to be provided by Dr. Simons as well as her staff. *
I , the patient or legal guardian of patient named above, acknowledge that the information I have provided above is true to the best of my knowledge. Please type your name below. *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy