COVID Questionnaire

COVID 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:
Patient Name *

First Name Middle Name Last Name
Responsible Party
E-mail Address *
example@example.com
Have you, your child, or others accompanying you to today’s appointment or other recent acquaintances tested positive for or been diagnosed as having COVID-19 or any other communicable disease? *

Yes No
If yes, when?
Do you, your child, or others accompanying you to today’s appointment or other recent acquaintances have:
A Fever (defined as above 99.6 degrees)? *

Yes No
A Cough? *

Yes No
Shortness of Breath and/or Trouble Breathing? *

Yes No
Persistent Pain, Pressure, or Tightness in the Chest? *

Yes No
Signature
I understand that if the answer to any of these questions is yes, I will be asked to reschedule today’s orthodontic appointment.
Patient/Parent’s Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

Signature