Patient Advisory and Acknowledgment
Dear Patient,

You have come to our office today for dental evaluation and/or treatment that will be done during the COVID-19 pandemic. Please be advised of the following:

While our office complies with State Health Department and the Centers for Disease Control and Prevention infection control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees.

Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge.

In order to reduce the risk of spreading COVID-19, we have asked you a number of screening questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.
Sign in to Google to save your progress. Learn more
Patient / Responsible Party *
Are you currently awaiting the results of a COVID-19 test? *
Do you have a fever? *
Do you have any shortness of breath? *
Do you have a dry cough? *
Do you have a runny nose? *
Do you have a sore throat? *
Do you have sneezing, watery eyes, and/or sinus pain/pressure that is unusual and not related to seasonal allergies? *
Have you experienced headaches, fatigue, or weakness? *
Have you lost your sense of taste and/or smell? *
Within the last 14 days, have you traveled to any foreign country? *
Within the last 14 days, have you traveled within the United States? *
Clear form
Never submit passwords through Google Forms.
This form was created inside of Piskai Orthodontics. Report Abuse