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?
Yes
No

If so, when?

Do you, your child, or others accompanying you to today’s appointment have:
A Fever (defined as above 38 Celsius)
A Cough
Shortness of Breath and/or Trouble Breathing
Persistent pain, pressure or Tightness in the chest?
None

Do you have fever or have you felt hot or feverish recently (14-21 days)?
Yes
No

Are you having shortness of breath or other difficulties breathing?
Yes
No

Do you have a cough?
Yes
No

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Yes
No

Have you experienced recent loss of taste or smell?
Yes
No

Has the patient traveled in the past 14 days?
Yes
No

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
Date Of Birth

Parent/Guardian Name (If under 18)
Patient/Parent’s Signature

Date: