11800 Sunrise Valley Dr., Suite 200, Reston, VA, 20191
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Sleep Solutions
Treating Temporomandibular Dysfunction (TMD)
Orofacial Myofunctional Therapy
Craniofacial Orthopedics
Interceptive Orthodontics
FAQs Page
Our Blog
Our Team
Testimonials
Contact
Resources
Patient Forms
Virtual Consultations
COVID-19 Office Procedures
Pediatric Sleep Questionnaire
Quality of Life Questionnaire
Online Bill Payment
Billing and Financial
Home
Sleep Solutions
Treating Temporomandibular Dysfunction (TMD)
Orofacial Myofunctional Therapy
Craniofacial Orthopedics
Interceptive Orthodontics
FAQs Page
Our Blog
Our Team
Testimonials
Contact
Resources
Patient Forms
Virtual Consultations
COVID-19 Office Procedures
Pediatric Sleep Questionnaire
Quality of Life Questionnaire
Online Bill Payment
Billing and Financial
Call
703-646-9950
COVID-19 Patient Advisory Form
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COVID-19 Patient Advisory Form
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Name
*
First
Last
Birthdate DD/MM/YY
*
Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
*
Yes
No
Are you/they having shortness of breath or other difficulties breathing?
*
Yes
No
Do you/they have a cough?
*
Yes
No
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
*
Yes
No
Have you/they experienced recent loss of taste or smell?
*
Yes
No
Are you/they in contact with any confirmed COVID-19 positive patients? (Patients who are well but who have a sick family memeber at home with COVID-19 should consider postponing elective treatment.)
*
Yes
No
Is your/their age over 60?
*
Yes
No
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
*
Yes
No
Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)
*
Yes
No
Specific to children, have they developed any rash in the extremities in the last 14 days (in arms, legs, abdomen)
*
Yes
No
Have you partaken in international travel within the last 14 days?
Yes
No
Signature of Patient, Parent or Legal Guardian
*
First
Last
Entering your name here is the same as submitting your signature on this document and proof of completion of this form.
Name if Patient is a Minor
First
Last
Relationship to Patient
Message
Submit
X
Welcome to
Airway and Sleep Group
For appointments call
703-646-9950.
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