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 100.4 degrees) A Cough Shortness of Breath and/or Trouble Breathing Persistent pain, pressure or Tightness in the chest? None Have you experienced loss of taste or smell? 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.
Patient Name Responsible Party Patient/Responsible Party
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