Have you confirmed your upcoming appointment? *

Your appointment confirmation allows us ensure that we are able to see your patients in the safest environment possible, allowing for social distancing & minimizing wait times - please assist us by confirming your visit as soon as possible, we appreciate your help!

Yes I've confirmed via text (replying "C" to the confirmation text)

Yes I've confirmed via email (by clicking "Confirm" on the confirmation email)

No - if not confirmed please do so that we can continue to reserve this spot for you.

Please confirm you have read our updated check-in protocol above and will comply to aid us in our efforts to keep our team, patients & community safe.

Yes I have read and will follow the updated check-in protocol to help in maintaining a safe environment at Tri-valley Orthodontics.

No I am unable to comply with the above guidelines - if No, please send us an email at info@tri-ortho.com so we can evaluate your specific circumstances.

Today's Date *

MM

DD

YYYY

Your Name *

First Name

Last Name

Patient's Name (if different)

First Name

Last Name

Phone *

(###)

###

####

Do you or does a member of your household currently have a fever (100 degrees F or above) have you experienced a fever in the last 14 days? *

Yes

No

Have you or a member of your household experienced more than one of the following symptoms: difficulty breathing, tightness in the chest, shortness of breath, dry cough, sore throat, muscle pain, headache or nausea, new loss of taste or smell - currently or within the last 14 days? *

Yes

No

Have you or any member of your household experienced any other flu-like symptoms, such as gastrointestinal upset, headache 
or fatigue? *

Yes

No

Have you or a member of your household come into contact with a patient with a suspected or confirmed coronavirus infection within the past 14 days? *

Yes

No

Have you been tested for COVID-19 in the last 14 days? *

No I have not been tested

Yes - test was positive

Yes - test was negative

Yes - waiting on results still

Have you or any of your household members traveled outside the U.S. in the past 14 days? Or have you traveled domestically within the United States by commercial airline, bus or train within the past 14 days?

Yes

No

As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as "Coronavirus" at any time or in any place. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so. Despite our careful attention to sterilization, disinfection and use of personal barriers, there is still a chance that you could be exposed to the illness just as you might be at your gym, grocery store, or favorite restaurant. "Social Distancing" nationwide has reduced the transmission of the Coronavirus. Although we have taken extreme measures to provide social distancing in our practice, due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, orthodontist and orthodontic staff at all times. Although exposure is unlikely, do you accept the risk and consent to treatment? *

Yes

No

For the duration of the COVID-19 pandemic, Tri-Valley Orthodontics will be requiring all patients who are seen at the office to "sign" this document. By typing your full name below you signify that the above is true as marked, that you understand the above information and associated risks. I understand that certain answers to the above questions, may result in being asked to reschedule today’s orthodontic appointment for the safety of our patients & team. Please sign by typing your Full Name: *

First Name

Last Name