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 prior to your scheduled appointment.
Patient's First and Last Name *

First Name Last Name
Today's Date *

Month Day Year
Email address *
Are you fully vaccinated for COVID-19? *

Yes No
Has it been at least 2 weeks since your second dose of the COVID-19 vaccine? *

Yes No Not applicable
Do you have a fever or above normal temperature? *

Yes No
Are you experiencing more than one of the following symptoms : shortness of breath, dry cough, sore throat, unexplained muscle pain, headache or nausea, new loss of taste or smell? *

Yes No
Even if you don't currently have any of the above symptoms, have you experienced more than one of these symptoms in the last 14 days? *

Yes No
Have you been advised to quarantine due to close contact with someone diagnosed with COVID-19? *

Yes No
Have you been tested for COVID-19 in the last 14 days?

Yes No
Have you traveled out of state or country in the last 14 days? *

Yes No
If yes to any of the previous questions *except those about vaccination*, 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.
Should be Empty:

Berkeley and Orinda Orthodontics Patient Screening Form