Patient COVID-19 Screening Form

Berkeley and Orinda Orthodontics Patient Screening Form

Thank you for taking an active role in helping Berkeley and Orinda Orthodontics protect our patients and staff from COVID-19. Please complete this short form 48 hours prior to your scheduled appointment. Please keep in mind that we will ask you to fill this out once again at the start of your appointment.
Patient's First and Last Name *

First Name Last Name
Today's Date *

Month Day Year
Email address *
Do you have fever or have you felt hot or feverish recently (within the past 14-21 days)? *

Yes No
Are you having shortness of breath or other difficulties breathing? *

Yes No
Do you have a cough? *

Yes No
Any other flu-like symptoms, such as sore throat, gastrointestinal upset, headache, body aches, or fatigue, chills or repeated shaking/shivering? *

Yes No
Have you experienced a recent loss of taste or smell? *

Yes No
Are you or have you been in contact with any suspected or confirmed COVID-19 positive patient(s)? *

Yes No
Within the last 10 days have you been diagnosed with Covid-19 or had a test confirming you have the virus?

Yes No
Are you over the age of 60? *

Yes No
Do you have heart disease, lung disease, kidney disease, diabetes, or auto-immune disorders? *

Yes No
Have you traveled in the past 14 days to any regions heavily affected by COVID-19? *

Yes No
Has a parent or another household family member taken a test recently for Covid-19?

Yes No
If yes to previous question please explain:
I declare that the selections above are true and correct to the best of my knowledge. I understand that a false statement may forfeit my ability to receive care. *

Clear
The doctors and staff at Berkeley and Orinda Orthodontics thank you for your efforts. - Drs. Kasrovi, Meyer, Kim, Ung, Hoang, and Ting
By clicking submit, I acknowledge that Berkeley and Orinda Orthodontics will use this information to comply with the California Dental Board screening requirements.
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Berkeley and Orinda Orthodontics Patient Screening Form