COVID-19 Screening

If you have been exposed to a communicable disease prior to your orthodontic appointment, you may spread the disease 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 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: