Please complete the following patient screening and consent form. Identify, patient name, age, and who completed the form. This is a pre-screening only. 

Upon arrival at the office you will be asked to sanitize your hands, have your temperature taken, as well as answer these questions again.

Please be advised, that at the present time, only patients are allowed in the office, (if a parent/guardian is needed, they will follow the same protocol. Otherwise, please wait in your vehicle or just outside of our office.

If you have answered YES to any questions 1 – 7, please call our office to discuss, and we can assess any risks.

I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to my scheduled appointment with Dr. Neal Palmer/Palmer Orthodontics.

Please consent by typing full name of patient if over 18.

Or, consenting parent/guardian if under 18.