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?
Have you or your child been exposed to someone in the last two weeks with a known positive COVID test?
Do you, your child, or others accompanying you to today’s appointment have:
A Fever (defined as 100.0 degrees or higher)
Shortness of Breath and/or Trouble Breathing
Persistent pain, pressure or Tightness in the chest?
I understand that if the answer to any of these questions is yes, I will be asked to reschedule today’s orthodontic appointment.
Patient/Responsible Party Signature: