COVID-19 Screening Questionnaire
The following questions are to be answered for the patient:
Are you experiencing any Covid symptoms today?
Have you tested positive for Covid in the past 14 days?
Have you received the Covid vaccine?
Have you traveled outside of Wisconsin or internationally in the past 10 days?
If you’ve answered YES to any of the above questions, we ask that you provide an explanation and/or approximate dates of illness or vaccination(s) below. Please be aware that there is a possibility that today’s appointment may need to be rescheduled to a later date.
Number to Call at Time of Appointment
*All additional people entering the office must wear a mask and be free of Covid symptoms.
If you, your child, or others accompanying you into the practice experience any COVID-19 symptoms within 10 days of their appointment, please contact our office.
Patient/guardian agrees to give consent for orthodontic treatment in the office today.
We thank you for your understanding in implementing these measures which are designed to preserve the health and safety of our patients and staff. If you have any questions or comments in relation to this COVID-19 questionnaire and the protocols in place in our office, we would appreciate your feedback.
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