Bibby Orthodontics Wellness Screening
We are looking forward to resuming Orthodontic care in the safest possible way for both patients and staff. Part of that includes having a Wellness Screening & Treatment Consent form completed for EACH patient no sooner than 24 hours PRIOR to their appointment. Please text us: 250-354-4354 or email: records@drbibby.com if you have any questions. In the case of a very young child or complex needs the accompanying person (ANYONE ENTERING OUR OFFICE) must also fill out this screening form. Masks are required.
Email address *
Best phone number to reach you *
Your name (Parent or Guardian if patient is under 19 yrs) *
Patient name *
In the last 14 days, has the patient (or any member of the household or close contacts) had any of the following? *
Yes
No
Fever (above 99.6 F / 37.5 C )
Cough, Sore throat
Shortness of breath or difficulty breathing
Loss of sense of smell or taste
Persistent pain, pressure, or tightness in the chest
Travel outside of British Columbia
Has the patient, a member of the household or a close contact had any of the following? *
Yes
No
Diagnosis of COVID-19 infection
Waiting on test results for COVID-19
Symptomatic but not tested for COVID-19
Been advised to Self Isolate
If Yes to any of the Health questions Please Elaborate.
If diagnosed with COVID-19 infection, when?
MM
/
DD
/
YYYY
If the answer to any of these questions changes before the appointment, I agree to notify Bibby Orthodontics by text or email (above) as soon as possible. *
Any broken brackets, wire issues, or concerns? *
Treatment Consent: Thank you for your continued trust in our practice. Please be assured that our office has always followed the regulations for sterilization and infection control from the BC College of Dental Surgeons and we will continue to do so. However, it is possible to contract a communicable disease such as a cold or the flu (and including COVID-19 infection) in any shared space. Our office has implemented measures for physical distancing and added a number of new protocols to enhance our level of safety and to reduce the risk of disease transmission. However, due to the nature of orthodontic treatment, a 2 metre distance is not possible between the patient, clinical staff, doctor, and sometimes other patients. Clicking "yes" below indicates that the risks involved are accepted and that consent is given for treatment to be provided at the office of Bibby Orthodontics. *
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