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?



If so, when?


Do you, your child, or others accompanying you to today’s appointment have:






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/Parent’s Signature​

 
Date: