COVID-19 Questionnaire
There is an increased risk that SARS-CoV-2 can be transmitted in any place of public accommodation, including an orthodontic office. Please complete this questionnaire to help protect the safety of the orthodontic office and the patients, staff and other individuals who come upon the premises. Smile Logic Orthodontics follows State and Federal regulations and recommended personal protection and disinfection protocols to limit transmission of communicable diseases like COVID-19.
Please complete this form on the day of your visit before you enter our office.
Name of patient *
Date of office visit *
Has the patient recently had recent exposure, positive viral test, or symptoms commonly associated with COVID-19? *
Exposure is defined as close contact (within 6 feet for at least 15 minutes) with a person who either (A) has symptoms or laboratory-confirmed disease at the time of contact, or (B) develops symptoms or laboratory-confirmed disease within 48 hours after contact. Symptoms include fever, shortness of breath, dry cough, difficulty breathing, running nose and/or sore throat.
Does the patient have underlying conditions that increase susceptibility or risk of complications from COVID-19? *
Is anything loose, broken, lost or bothering the patient? *
Where will accompanying family members be during the patient's appointment? *
Name of person signing on behalf of the patient *
Electronic signature consent *
Acknowledgement *
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