Ferris Orthodontics Check In

Dear Patient:

You have come to our office today for orthodontic services that will be done during the COVID-19 pandemic. Please be advised of the following:

While our office complies with State Health Department and CDC to prevent the spread of the COVID-19 virus, we cannot make any guarantees.

Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge.

In order to reduce the risk of spreading COVID-19, we will ask you a number of "screening" questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.

This questionnaire only needs to be submitted one time. At future appointments you will verbally be asked if there are any changes to the questionnaire since your last visit.

Choose Your Location*

BoerneBulverdeLeon Springs

Patient Name*

First NameLast Name

Responsible Party Name

First NameLast Name

Today's Date & Time

DateHourMinutesAM/PM Option

Are you currently awaiting the results of a COVID-19 test?*

YesNo

Do you have a fever?*

YesNo

Do you have any shortness of breath?*

YesNo

Do you have a dry cough?*

YesNo

Do you have a runny nose?*

YesNo

Do you have a sore throat?*

YesNo

Do you have sneezing, watery eyes, and/or sinus pain/pressure that is unusual and not related to seasonal allergies?*

YesNo

Have you experienced headaches, fatigue, or weakness?*

YesNo

Have you lost your sense of taste and/or smell?*

YesNo

Within the last 14 days, have you traveled to any foreign country?*

YesNo

Within the last 14 days, have you traveled within the United States?*

YesNoOther

Patient Advisory and Acknowledgment