Patient Screening Form - Blue Wave Orthodontics
  • Pre-appointment*
     - -
  • In-office*
     - -

  • Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?

  • Pre-appointment*
  • In-office*

  • Are you/they having shortness of breath or other difficulties breathing?

  • Pre-appointment*
  • In-office*

  • Do you/they have a cough?

  • Pre-appointment*
  • In-office*

  • Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

  • Pre-appointment*
  • In-office*

  • Have you/they experienced recent loss of taste or smell?

  • Pre-appointment*
  • In-office*

  • Are you/they in contact with any confirmed COVID-19 positive patients?

  • Pre-appointment*
  • In-office*

  • Is your/their age over 60?

  • Pre-appointment*
  • In-office*

  • Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

  • Pre-appointment*
  • In-office*

  • Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)

  • Pre-appointment*
  • In-office*

  • Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

  • Should be Empty: