COVID-19 Screening

COVID-19 Screening
If you have been exposed to a communicable disease prior to your orthodontic appointment, you may spread the disease 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
When?

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

A fever (defined as above 99.6 degrees)A coughShortness of breath and/or trouble breathingPersistent pain, pressure or tightness in the chestNone
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
Do you have a cough?*

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

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

YesNo
Are you in contact with any confirmed COVID-19 positive patients?*

YesNo
Is your age over 60?*

YesNo
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*

YesNo
Have you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)*

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
Date of Birth*

MonthDayYear
Date
Parent/Guardian Name (If under 18)

First NameLast Name
Patient/Parent’s Signature*

Clear
Date*

MonthDayYear
Should be Empty: