Weiss & Tor Orthodontics: COVID-19 Health Form

To our orthodontic family and friends, thank you for your support and patience in the past weeks as our office has been closed in compliance with our Governor's directives during the peak of the COVID-19 pandemic. We are very much looking forward to resuming orthodontic care in the safest possible way for both patients and staff. Part of that initiative includes the attached Wellness Screening and Treatment Consent that we request is returned prior to EACH APPOINTMENT. Please call or email the office if you have any questions, and we will see you soon!

Your Name:*

Patient Name (if different):

Email Address:*

In the last 14 days, has the patient (or any member of the household) had any of the following?

Fever (over 99.6 degrees F):*

YesNo

Coughing:*

YesNo

Shortness of breath or difficulty breathing:*

YesNo

Persistent pain, pressure or tightness in chest:*

YesNo

Loss of sense of smell:*

YesNo

Travel by airplane or cruise ship:*

YesNo

Has the patient, a family member, or any known close contact had any of the following occur?

Diagnosis of COVID-19 infection, or any other communicable disease:*

YesNo

Waiting on results of test for COVID-19 infection:*

YesNo

If the patient, family member, or close contact has been diagnosed with COVID-19 infection, when did that occur?:

Date

Weiss & Tor Orthodontics: COVID-19 Health Form - Middleburg Heights

Wellness Screening & Treatment Consent