COVID-19 Supplemental Health Questionnaire

If you have been exposed to a communicable disease, you may spread the disease to the orthodontist, orthodontic staff, or other patients/parents in the practice. Therefore, prior to each appointment, we will be asking the following questions to reduce the chances of transmission:

Do you, your child, others accompanying you to today's appointment or anyone you have recently been in contact with have any of the following symptoms?

Fever (defined as above 99.6 degrees)?

Yes
No

Cough?

Yes
No

Shortness of breath and/or trouble breathing?

Yes
No

Persistent pain, pressure, or tightness in the chest?

Yes
No

Have you, your child, others accompanying you to today's appointment or anyone you have recently been in contact with tested positive for or been diagnosed as having COVID-19 or any other communicable disease?

Yes
No

I understand that if the answer to any of these questions is yes, I may be asked to reschedule today's orthodontic appointment to a later date.

Yes

Patient Name


Parent/Guardian Name (if applicable)


Relation



Patient/Parent/Guardian Signature

OFFICE

HOURS


Monday: 8:30AM—5:00PM

Tuesday: 8:30AM—5:00PM

Wednesday: 8:30AM—5:00PM

Thursday: 8:30AM—5:00PM

Friday: 8:30AM—5:00PM

Saturday & Sunday: Closed

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FREE PARKING AVAILABLE