Dear Patients, Parents and/or Guardians,
Due to the COVID-19 pandemic, it has become necessary that we ask all parents/patients to complete the following questionnaire. Please make sure to fill out this form before you come in for your appointment, but not sooner than 24h prior to it.
QUESTIONNAIRE
Has the patient or anyone in the patient's household recently had, or currently have, any of the following symptoms? (please check any/all that apply)
- Sore Throat
- Cough
- Fever of more than 100 degrees
- Persistent pain. pressure or tightness in the chest
- Feeling ill in any way
Yes
No
Has the patient or anyone in the patient's household, come into contact with anyone who may have tested positive for COVID-19 within the last 14 days?
Yes
No
Did you respond Yes to either of the above questions?
Yes - Please call our office now: 540-720-4178
No - Please continue to the next section of this form
IF YOU RESPONDED YES TO EXPOSURE OR ANY OF THE ABOVE SYMPTOMS PLEASE CALL US NOW:
540-720-4178
Please continue if you answered "No" to the previous question.
By clicking below, I acknowledge that there is always a risk when not social distancing. While exposure is unlikely due to all precautions taken, I accept this risk and consent to treatment today.
Responsible Party's Name
Responsible Party's Email
(optional)
Responsible Party's Mobile Phone
(optional)
Patient's Full Name
Today's Date
Is today's patient experiencing an oral emergency?
Yes
No
Please tell us about your car so we may find you more easily: Make/Model, Color & Plate #
Please call the office at 540-720-4178 or text 540-847-5874 to let us know you have arrived, and have submitted your health questionnaire. We will instruct you when to enter the office. Temperatures will be taken upon entry.
By submitting this form you confirm that all of the above questions have been answered truthfully.
Submit
By sharing this data, you authorize its use including an opt-in to receive emails and text messages from Lupi Orthodontics per the Terms of Use.
To withdraw or limit consent please contact us.