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:

Have you, your child, or others accompanying you to today’s appointment or other recent acquaintances tested positive for or been diagnosed as having COVID-19 or possibly exposed to COVID-19?


Do you, your child, or others accompanying you to today’s appointment or other recent acquaintances have:

A Fever? (defined as above 99.6 degrees)



A Cough, sore throat or runny nose?



Shortness of Breath and/or Trouble Breathing?



Persistent Pain, Pressure, or Tightness in the Chest?



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



Have you been tested for COVID-19 and awaiting results?



Have you recently lost or had a reduction in your sense of smell?



Have you traveled within the past 2 weeks?




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:


Date: