• Heights Orthodontics

    COVID-19 Patient Screening Form

  •  -  -
    Pick a Date
  • If you answer “Yes” to either question on shortness of breath or coughing, or if you answer “Yes" to any combination of two other symptoms and the patient does not need emergency care, consider rescheduling until symptoms resolve or until you can provide proof you are not infectious for COVID-19. We are happy to provide additional information regarding symptoms.

  • If the answer is “Yes” and you do not need emergency care, do not schedule an appointment unless it has been more than 7 days since symptoms first appeared and 3 consecutive days without a fever (use of fever-reducing medication to treat fever does not count toward these days).


  • If positive, we will reschedule your appointment until you have been cleared to return by a physician with proper verification.  If you are still waiting on the results, please reschedule your appointment until after the results are known.

  • If yes, was the area a hot zone for COVID-19 cases? Did you follow physical distancing precautions and wear a mask while in public? Please use professional judgement when determining whether to proceed with the appointment.

  • Patient signature required at appointment:


    I agree to notify the dental practice if within 14 days I become ill with COVID-19 symptoms or test positive for COVID-19. I understand the dental practice has a legal and ethical obligation to inform me if a staff person I had contact with tested positive for COVID-19 within 14 days.

  • Clear
  • Should be Empty: