COVID-19 Pandemic Orthodontic Treatment Health Form

COVID-19 Pandemic Orthodontic Treatment Health Form

We have adopted a number of new office procedures to ensure your safety and the safety of our staff. Please fill out this form and press the large button at the bottom. Thanks very much, Dr. Gina Ball

    Please complete and return a copy of this form to the dental office at least 24 hours in advance of your scheduled appointment.



    I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have orthodontic treatment completed during the COVID-19 pandemic. Initials

    I agree to notify Mountain Orthodontics (and reschedule the appointment) of any change in the patient’s health or high risk contacts prior to the appointment. If symptoms appear within 14 days after the appointment I will also notify Mountain Orthodontics. Initials

    Questions Answer Yes or No
    1. Do you have a fever or have felt hot or feverish anytime in the last two weeks?
    2. Do you have any of these symptoms: Dry cough? Difficulty breathing? Sore throat or painful swallowing? Runny nose/sneezing/post-nasal drip? Chiils? Muscle aches? Headache? Fatigue?
    3. Have you experienced a recent loss of smell, taste or appetite?
    4. Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19?
    5. Have you returned from travel outside of Canada in the last 14 days?
    6. Have you returned from travel within Canada from a location known affected with COVID-19?
    7. Are you over the age of 70?
    8. Do you have any of following: Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder

    PIease note that no data transmission over the internet can be guaranteed to be 100% secure. As a resuIt, we cannot guarantee the security of any information you transmit to us over the internet, and you do so at your own risk. If you wouId prefer to contact us by teIephone to compIete this screening questionnaire, pIease caII: 604-892-5969

    We have implemented new procedures to help keep all of us safe and stop the spread of Covid-19. We may look different with our PPE on, but we promise it is still us underneath it! 🙂

    Please brush and floss before your appointment. Our tooth brushing station is closed for now.

    Please stay in your vehicle and call us when you arrive for your appointment. We will advise you if you may come up to the office. If we are not ready for you we will call back and let you know when you may come to the office.

    Only the patient is allowed in the office. We will make accommodations if there is a need for someone to accompany the patient for such things as age. Please discuss this with us prior to the appointment so we can prepare. The accompanying person must wear a mask and answer health questions. Please ensure you have your own mask as we are not able to provide one for you.

    A member of our staff will meet the patient at the door, give them some hand sanitizer to use, and take their temperature and verbally confirm they feel ok.

    When the appointment is over the patient will again use the hand sanitizer as they leave the office.



    Office Contact Information:
    Mountain Orthodontics | #105-40258 Glenalder Pl. Squamish, BC V8B 0G2
    604-892-5969 | info@mountainorthodontics.com