COVID-19 Health Questionnaire

In the era of COVID-19, we need to do everything possible to protect our patients and our team. Therefore, prior to each appointment, we require you to answer the following questions within 24 hours prior to your visit:

 
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:




I understand that if the answer to any of these questions is yes, I will be asked to reschedule today’s orthodontic appointment.

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Patient/Parent’s Signature​:

 
Date: