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Casaus Orthodontics Wellness Screening Form
Please complete this form WHEN YOU ARRIVE FOR YOUR APPOINTMENT. Complete one form for each person entering the office (please limit to one companion). Dr. Casaus will review your responses and contact you for clarification if needed. You will receive a text when we are ready for you to enter the office. Thank you!
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* Indicates required question
Are you currently in our parking lot ready to be seen?
YES
NO (please wait to fill out this form WHEN YOU ARRIVE, or text the name of the patient to 505-508-4939 when you arrive)
First and Last Name of the person entering the office:
*
Your answer
Date of Birth of the person entering the office:
*
Your answer
Name of the patient you are accompanying: (answer "Self" if you are the patient)
*
Your answer
Cell phone number where you can be reached right now:
*
Your answer
Have you tested POSITIVE for COVID-19?
*
YES
NO
Required
If yes, date quarantine ended?
Your answer
Have you had a fever, shortness of breath, or loss of taste/smell in the past two weeks?
*
YES
NO
Required
Have you experienced cough, runny nose, headache, fatigue, or stomach upset in the past two weeks?
*
YES
NO
Required
Have you been told to quarantine due to contact with a COVID-positive person?
*
YES
NO
Required
If yes, date quarantine ended:
Your answer
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