Register

Covid Screening Registration for Dental/Medical Offices

If you are a patient and have got a link to complete covid-19 questionnaire from your dentist, please STOP and contact your dental office.

ORTHODONTIST OFFICE : CLICK HERE
SEE A DEMO : CLICK HERE
Name*
First Last
Username*
Your url will be based on the username like us.patientriver.com/username
Office Name*
Email*
THIS IS YOUR FRONT DESK OR OFFICE EMAIL. WHEN YOUR PATIENT COMPLETES THIS CONSENT, THIS EMAIL WILL RECEIVE PDF SUBMISSION. PLEASE MAKE SURE IT IS ACCURATE AND DONOT USE YOUR PERSONAL EMAIL.
Enter Email Confirm Email
Logo or Background*
Please choose your logo from your website. If you are using mobile phone, it is recommended to take screenshot of your website logo or background and crop it.
Accepted file types: png, jpg, jpeg.
Hide Age Question
As per California Dental Association, they don't recommend "Is your/their age over 60?" in screening questionnaire. Would you like to hide age/date of birth in Questionnaire?
YES
NO
Custom Consent
Would you like to add your custom consent?*
This consent will be shown to your patients in addition to questionnaire.
YES
NO
You wont be able to change your consent once your page is created. You will have to contact info@patientriver.com to modify it.
Consent Label*
Consent Text*
I confirm that the username and email address provided is accurate.*
You would not be able to change email address / username, once your page is created.
YES
NO
Payment Terms & Condition.*
There is no monthly fee however one time fee of $50 is requested to use this service. This helps me to cover development, hosting server, email server and support expenses. This site is HIPAA compliant, all data is transmitted securely over SSL secure certificate. Patient data is not stored on the server. If your payment is not received with-in 24 hours, your page will become inactive. If you require signed BAA, please contact info@patientriver.com. All payments are non-refundable.
I agree to the payment policy.
Phone
This field is for validation purposes and should be left unchanged.

Covid Screening Registration for Dental/Medical Offices

Custom Consent