Bright Smile Orthodontics Wellness Form

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Please fill out this form and submit it within 24 hours of your appointment.

What is the patient's last name? *

What is the patient's first name? *

Cell phone number to best reach you at the time of the appointment: *

Has the patient or a member of your household been sick or had a fever within the last 10 days? *

Yes

Has the patient been having any of the following symptoms? *

Fever

Abdominal Pain

Pneumonia

Cough

Headache

Diarrhea

ARDS ( Acute Respiratory Distress Syndrome)

Shortness of Breath

Sore Throat

Vomiting

Muscle Aches

Loss of Smell or Taste

None of the above

Other:

Required

Has the patient been tested for COVID-19 after experiencing any of these symptoms? *

I have not experienced any of these symptoms or shown any signs of COVID-19

I showed these symptoms, got tested and it was positive

I showed these symptoms, got tested and it was negative

I have experienced these symptoms and have not been tested for COVID-19

If the answer yes to any of these questions changes prior to the scheduled appointment or any of these symptoms mentioned deem it necessary to do so, I agree to notify Dr. Starobinets' office , 201-794-9500 as soon as possible in order to keep her staff and other patients safe by rescheduling the appointment *

I understand

Treatment Consent: Please be assured that our office has always met or exceeded the requirements of sterilization and infection control from the CDC and OSHA , and will continue to do so. However it is possible to contract the COVID-19 virus (or any other communicable disease) in any public space. Our office has added a number of new technologies and techniques in effort to enhance our level of safety and further limit the risks that come with any business being open. However due to the nature of orthodontic treatment a six foot distance between staff/doctors and patients is not achievable during in office or non-virtual appointments. Please note we are taking every precaution possible in order to keep our patients and staff safe and healthy. 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. Julia Starobinets and her staff *

Yes, I consent to Orthodontic Appointment/Treatment

I , the legal guardian of the patient named above, acknowledge that the information I have provided above is true to the best of my knowledge. Please type your name below *

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