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?
EASTPOINT - 1103 North Point Blvd, Baltimore, MD 21224
LUTHERVILLE - 2324 W Joppa Rd, Lutherville-Timonium, MD 21093
ELLICOTT CITY - 10045 Baltimore National Pike, Ellicott City, MD 21042
CATONSVILLE - 1134 N. Rolling Rd, Catonsville, MD 21228
ELDERSBURG - 5961 Exchange Drive #114, 9266, Eldersburg, MD 21784
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?
Shortness of breath and/or trouble breathing
Persistent pain, pressure, or tightness in the chest
Muscle or body aches
Loss of taste or smell
Nausea, vomiting, or diarrhea
NONE OF THE ABOVE
Has the patient, or anyone accompanying the patient participated in any of the following in the last 14 days?
Travelled outside of the country
Travelled on an airplane, bus, or train
Travelled to a current "hot spot" or "red zone"
Attended a large gathering
NONE OF THE ABOVE
Has the patient been tested for COVID19?
Yes, and it was positive
Yes, and it was negative
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:
Yes, I accept the risk and consent to treatment
No, I do not wish to be seen at Baltimore Orthodontic Group today
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.
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