Wellness Screening & Treatment Consent

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We require that this Wellness Screening be filled out prior to EACH APPOINTMENT for EACH PATIENT.

Email *

Your name *

Patient name (if different) *

In the last 7 days, has the patient (or any member of the household) had any of the following? *

YES

Fever (over 99.6 F)

Coughing

Sore throat

Does the patient, a family member, or any known close contact have COVID-19? *

YES

Required

If the answer to any of these questions changes before the appointment, I agree to notify Dr. Celest Fernandez and the Robbinsville Orthodontics' team as soon as possible. Also, if the answer is yes to any of the previous questions, I understand I may be asked to reschedule the appointment. *

Yes, I understand

Send me a copy of my responses.

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