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 99.6 degrees) A Cough Shortness of Breath and/or Trouble Breathing Persistent pain, pressure or Tightness in the chest? None 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 Parent/Guardian Name (if patient is under 18 years old) Patient/Parent’s Signature
Date: