Wellness screening

Thank you for your support and patience in the past months as we strictly follow the NB Public Health guidelines. Please complete the Wellness Screening and return it prior to EACH APPOINTMENT.

Patient's Name Patient's Name First Last
Parent's name (if applicable) Parent's name (if applicable) First Last
Email
Cell phone number Cell phone number - ### - ### ####
Date of Birth Date of Birth / MM / DD YYYY

In the last 5 days have you or any member of your household:
(If "yes" to any of the below questions please contact the office prior to your arrival for appointment)
	yes	no
Had a positive Covid-19 rapid test or are currently waiting to hear the results of a PCR Test	Had a positive Covid-19 rapid test or are currently waiting to hear the results of a PCR Testyes	Had a positive Covid-19 rapid test or are currently waiting to hear the results of a PCR Testno
Experienced any Symptoms of Covid-19	Experienced any Symptoms of Covid-19yes	Experienced any Symptoms of Covid-19no
Had anyone in your family bubble test positive for a Covid 19 rapid test or Covid-19 PCR test	Had anyone in your family bubble test positive for a Covid 19 rapid test or Covid-19 PCR testyes	Had anyone in your family bubble test positive for a Covid 19 rapid test or Covid-19 PCR testno

I certify that I have provided truthful and accurate answers. If the answer to any of these questions changes before the appointment, I agree to notify MacKenzie Orthodontics' office as soon as possible. If the answer is yes to any of the previous questions, I understand that I will be asked to reschedule the appointment.

I certify that I have provided truthful and accurate answers. If the answer to any of these questions changes before the appointment, I agree to notify MacKenzie Orthodontics' office as soon as possible. If the answer is yes to any of the previous questions, I understand that I will be asked to reschedule the appointment. I agree.
Treatment Consent: Please, be assured that our office has always met or exceeded the requirements for sterilization and infection control from the Federal and Provincial Health Authorities and will continue to do so. Our office will provide for socially distant appointment scheduling, and also has added a number of new technologies and techniques to the practice to enhance the level of safety. However, it is possible to contract COVID-19 infection (or any other communicable disease) in any public space. Due to the nature of orthodontic treatment, a 6 foot distance is not possible between the orthodontic patient and clinical staff/doctor. Re-entering public life comes with some risks that we all must weigh, but we also want you to feel confident that our office is taking every step to keep our patient and staff safe during this difficult time. I consent to receiving orthodontic treatment at MacKenzie Orthodontics.

Treatment Consent: Please, be assured that our office has always met or exceeded the requirements for sterilization and infection control from the Federal and Provincial Health Authorities and will continue to do so. Our office will provide for socially distant appointment scheduling, and also has added a number of new technologies and techniques to the practice to enhance the level of safety. However, it is possible to contract COVID-19 infection (or any other communicable disease) in any public space. Due to the nature of orthodontic treatment, a 6 foot distance is not possible between the orthodontic patient and clinical staff/doctor. Re-entering public life comes with some risks that we all must weigh, but we also want you to feel confident that our office is taking every step to keep our patient and staff safe during this difficult time. I consent to receiving orthodontic treatment at MacKenzie Orthodontics. I agree.
Today's Date Today's Date / MM / DD YYYY
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