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Home
About
For New Patients
About Ortho
Treatments
Invisalign®
Contact

Call Us Today! (519)675-0330

Home
About
For New Patients
About Ortho
Treatments
Invisalign®
Contact

Home
About
For New Patients
About Ortho
Treatments
Invisalign®
Contact

Now Offering Virtual Appointments For New And Current Patients - Click Here To Get Started Today

BOOK APPOINTMENT | REFER A FRIEND | REFER A PATIENT | POST-APPOINTMENT SURVEY

COVID-19 Screening Questionnaire

Please fill out this questionnaire form. The questionnaire must be completed TWICE: First, TWO WEEKS BEFORE your appointment, and secondly, on the DAY OF your appointment. Failure to complete these steps could result in you being turned away. These steps are required due to guidelines provided by the Ministry of Health and our Royal College.

ALL PUBLIC WASHROOMS ARE CLOSED Please be sure to use facilities BEFORE coming to your appointment.

BRUSH YOUR TEETH BEFORE YOUR APPOINTMENT If the mouth is very dirty, we may need to reschedule your appointment

ONLY PATIENTS ARE ALLOWED TO ENTER THE LOCKED BUILDING

ALL PATIENT MUST BE WEARING A MASK, SCARF OR CLOTH OVER THEIR NOSE AND MOUTH TO ENTER Because of the lack of PPE, masks will NOT be supplied by our office. You must have a mask or covering to enter.

ALL PAYMENTS CAN BE DONE VIA ETRANSFER OR CREDIT CARD PRIOR TO APPOINTMENT

Name*
First Last
Email*
Phone*
Have you received the final (or second) vaccination dose more that 14 days ago?*
- Yes
- No
Has there been any changes to your medical history?*
- Yes
- No
Do you have any of the following symptoms:
Do you have any cold symptoms? Including a runny nose*
- Yes
- No
Fever and or chills*
- Yes
- No
New onset of cough or worsening chronic cough*
- Yes
- No
Shortness of breath*
- Yes
- No
Decrease or loss of sense of taste or smell*
- Yes
- No
If adult (18+ years): Unexplained fatigue/lethargy/Malaise/Muscle aches*
- Yes
- No
If child (Under 18): Nausea/Vomiting/Diarrhea*
- Yes
- No
have you tested positive for COVID-19 in the past 10 days or have you been told you should be isolating?*
- Yes
- No
Have you traveled outside of Canada in the past 14 days?*
- Yes
- No
Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?*
- Yes
- No
Treatment Consent*
Yes, I consent to orthodontic treatment.
Please be assured that our office has always met or exceeded the requirements set forth for sterilization and infection control from the RCDSO and PHO, and will continue to do so. However, it is possible to contract COVID-19 infection (or any other communicable disease) in any public space. Our office will provide for socially distant appointment scheduling, and has also added a number of new technologies and techniques to the practices to enhance our level of safety. However, due to the nature of orthodontic treatment, social distance is not possible between the orthodontic patient and the clinical staff/doctor.
Clicking “yes” above indicated that the risks involved are accepted, and consent is given for treatment to be provided by the office of Dr. Baby and Rojas.
Rules and Regulations*
I read and understand the clinic rules and regulations as listed below.
• ALL PUBLIC WASHROOMS ARE CLOSED Please be sure to use facilities BEFORE coming to your appointment.

• BRUSH YOUR TEETH BEFORE YOUR APPOINTMENT If the mouth is very dirty, we may need to reschedule your appointment

• ONLY PATIENTS ARE ALLOWED TO ENTER THE LOCKED BUILDING

• ALL PATIENT MUST BE WEARING A MASK, SCARF OR CLOTH OVER THEIR NOSE AND MOUTH TO ENTER Because of the lack of PPE, masks will NOT be supplied by our office. You must have a mask or covering to enter.

• ALL PAYMENTS CAN BE DONE VIA ETRANSFER OR CREDIT CARD PRIOR TO APPOINTMENT
Consent*
I certify that the information submitted in this questionnaire is true and correct to the best of my knowledge.
CAPTCHA

Baby & Rojas
Orthodontic Specialists

(519) 675-0330

Main Orthodontist Office

99 Horton St W Unit 100, London, ON N6J 4Y6

Orthodontist Locations

Orthodontist London
Orthodontist Wingham
Orthodontist Goderich

Business Hours

Monday- Friday 8:30a.m. – 5p.m.
Saturday Closed
Sunday Closed

BROWSE

About Us
Patients
Treatment Info
Invisalign
Contact
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About Us
Patients
Treatment Info
Invisalign
Contact
Sitemap
Privacy Policy

OUR MISSION

We strive to provide high quality care in a friendly and family oriented orthodontic practice in London, Goderich and Wingham.

VISIT US IN LONDON

MAIN ORTHODONTIST OFFICE