COVID-19 Screening

COVID-19 Screening

If you have been exposed to a virus (COVID-19) prior to your orthodontic appointment, you may spread the virus to the orthodontist, orthodontic staff and to other patients/parents in the practice. Therefore, prior to each appointment, we require you to answer the following questions:
Have you, your child, or others accompanying you to today’s appointment been tested positive for or been diagnosed as having COVID-19?*

YesNo

Do you, your child, or others accompanying you to today’s appointment have: **

Do you have fever or have you felt hot or feverish recently (14-21 days)?*

YesNo
Are you having shortness of breath or other difficulties breathing?*

YesNo
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?*

YesNo
Do you have a cough?*

YesNo
Have you experienced recent loss of taste or smell?*

YesNo
Has the patient traveled in the past 14 days?*

YesNo
If any of you have any of these symptoms or have recently tested positive for or been diagnosed with Covid-19, you will be asked to reschedule your orthodontic appointment.

By signing below, I certify that the above statements are true and correct to the best of my knowledge.
Patient Name*

First NameLast Name
Patient Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Parent/Guardian Name (If under 18):*

First NameLast Name
Date submitted*

MonthDayYear
Date
Patient/Parents Signature*

Clear
Should be Empty: