Please complete prior to appointment.
OX ORTHODONTIX
COVID-19 PATIENT SCREENING
Please check if you have experienced any of the following within the past 14days
COUGH
FEVER
SHORTNESS OF BREATH/DIFFICULTY BREATHING
CHILLS
MUSCLE PAIN
HEADACHES
SORE THROAT/TIGHTENING OF CHEST
LOSS OF TASTE
LOSS OF SMELL
Have you had contact with any person who has tested positive for COVID-19 within the past 14 days?
YES
NO
Have you traveled outside the United States within the past 12 weeks?
YES
NO
Name
First Name
Last Name
Signature
Clear
Date
-
Month
-
Day
Year
Date
A parent or guardian must sign if the patient is under 18 years of age.
Submit
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