Wellness Screening & Patient Disclosure
We can’t wait to see your smiling faces again! Your safety and wellness are very important and we have some new COVID -19 precautions in place to keep you safe while resuming your orthodontic care.

Please complete the attached Wellness Screening and Patient Disclosure for each patient prior to EACH APPOINTMENT.

Please call (253) 661-7228 or email the office if you have any questions, and we will see you soon!
Email address *
Your Name *
Patient Name (If Different) *
Relation to Patient *
In the last 14 days, has the patient (or any member of the household) had any of the following? *
Yes
No
Fever or above normal temperature?
Experienced shortness of breath or had trouble breathing?
Dry cough?
Runny nose?
Lost or had a reduction in your sense of smell and/or taste?
Sore throat?
Travled by airplane?
Has the patient, a family member, or any known close contact had any of the following occur? *
Yes
No
Tested postive for COVID-19?
Been tested for COVID-19 and are awaiting results?
If the patient, family member, or close contact has been diagnosed with COVID-19 infection, when did that occur?
MM
/
DD
/
YYYY
If the answer to any of these questions changes before the appointment, I agree to notify Dr. VanDevanter's office as soon as possible. Also, if the answer is yes to any of the previous questions, I understand I will be asked to reschedule the appointment. *
Treatment Consent: Please be assured that our office has always met or exceeded the requirements set forth for sterilization and infection control from the CDC and OSHA, and will continue to do so. However, it is possible to contract COVID-19 infection (or any other communicable disease) in any public space. Our office will provide for socially distant appointment scheduling, and also has added a number of new technologies and techniques to the practice to enhance our level of safety. However, due to the nature of orthodontic treatment, a 6 foot distance is not possible between the orthodontic patient and clinical staff/doctor. Re-entering public life comes with some risks that we all must weigh, but we also want you to feel confident that our office is taking every step to keep our patients and staff safe during this difficult time. Clicking "yes" below indicates that the risks involved are accepted, and that consent is given for treatment to be provided by the office of Camille VanDevanter DDS, MSD. * *
A copy of your responses will be emailed to the address you provided.
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