Baltimore Orthodontic Group COVID-19 Health Questionnaire and Consent
1) Please fill out this questionnaire only ***IF YOUR APPT AT BOG IS IN THE NEXT 2 HOURS**. Earlier entries will be discarded.
2) If you have just arrived at the office, complete this questionnaire, and then text your NAME and "I'm here" to the appropriate text number provided in the appointment reminder email.
3) Please wait in your car until you we admit you into the office.
Where is your next appointment located? *
What is the patient's full name? *
What is the best cell phone number to reach you during the appointment? *
Has the patient had any of the following symptoms in the last 14 days? *
Required
Has the patient, or anyone accompanying the patient participated in any of the following in the last 14 days? *
Required
Has the patient been tested for COVID19? *
Has the patient (or any others accompanying the patient) had recent interactions with people who have tested positive for COVID-19, or any other communicable disease? *
Please read the consent form below: *
Captionless Image
I , the patient or legal guardian of patient named above, acknowledge that the information I have provided above is true to the best of my knowledge. Please type your name below to sign this document. *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy