Supplemental Health Questionnaire

You have come to our office today for a routine dental evaluation and/or treatment that will be done during the COVID-19 pandemic.  

Please be advised of the following:

While our office complies with State Health Department and the Centers for Disease Control and Prevention infection control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees.

Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus.  However, since we are a place of public accommodation, other persons (including other patients) could be infected, with our without their knowledge.

If you have been exposed to COVID-19 , 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:

Within the past 14 days, have you had a known exposure to any individual suspected or confirmed to have COVID-19 or who has traveled to a location after which self-quarantine is recommended? For staff: You may answer "No" if you are a health care worker whose only exposure to invividuals with suspected or confirmed COVID-19 has been in a health care setting in which you were wearing apporpriate personoal protective equipment.

Did you/your child brush thoroughly before coming to this appointment so that there is no visible plaque on the teeth?

I understand that if the answer to any of these questions is "yes" (except about brushing teeth), I will be asked to reschedule today’s orthodontic appointment.

A weakened or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID‐19. Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us.

I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system.

By signing this document, I acknowledge that the answers I have provided above are true and accurate.

Patient/Parent/Guardian Signature: