Have you, your child, or others accompanying you to today’s appointment been tested positive for or been diagnosed as having Covid-19?
If so, when?
Do you, your child, or others accompanying you to today’s appointment have:
A Fever (defined as above 99.6 degrees)
Shortness of Breath and/or Trouble Breathing
Persistent pain, pressure or Tightness in the chest?
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.
Parent/Guardian Name (if patient is under 18 years old)