COVID-19 Questionnaire

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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.

Updated 8/18/2022 to comply with the New Jersey Division of Consumer Affairs DCA Administrative Order N. 2022-01 modifying order DCA-2021-11; and the updated requirement memo dated 8/17/2022.

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 or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headaches, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and/or diarrhea.

No symptoms today and no symptoms, no exposure, and no positive viral test within the past 14 days.

Yes, the patient has had symptoms, exposure, and/or a positive viral test within the past 14 days.

Does the patient have underlying conditions that increase susceptibility or risk of complications from COVID-19? *

No underlying conditions.

Yes, the patient has underlying conditions including age 50 or older, cardiovascular disease, chronic lung disease (asthma, emphysema, COPD), chronic renal disease, neurologic disease, and/or other chronic disease.

Is anything loose, broken, lost or bothering the patient? *

Nothing is loose, broken, lost or bothering the patient.

Other:

Where will accompanying family members be during the patient's appointment? *

Family members will wait in their car during the patient's procedure.

Family member will be physically present during the patient's procedure. Within the past 14 days, the companion has NOT had symptoms, including fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headaches, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and/or diarrhea. Within the past 14 days, the companion has NOT had a known exposure to any individual, suspected or confirmed to have COVID-19 or who has traveled to a location after which self-quarantine is recommended.

Name of person signing on behalf of the patient *

Electronic signature consent *

I consent to the use of electronic records and electronic signatures in place of written documents and handwritten signatures as described at https://www.smilelogicortho.com/esign/

Required

Acknowledgement *

I acknowledge and understand that there is an increased risk that COVID-19 can be transmitted in any place of public accommodation, including an orthodontic office, and I have been informed that my orthodontist desires to protect the safety of the orthodontic office and the patients, staff and other individuals who come upon the premises.

Required

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