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COVID-19 QUESTIONNAIRE
 

If you have been exposed to a communicable disease, you may spread the disease to the orthodontist, orthodontic staff, or other patients/parents in the practice. Therefore, prior to each appointment, we will be asking you to fill out the following questions to reduce the chances of transmission:

Do you, your child, others accompanying you to today’s appointment or anyone you have recently been in contact with have any of the following symptoms?

Fever (defined as above 99.6 degrees)?  

Cough?  

Shortness of breath and/or trouble breathing? Persistent pain, pressure, or tightness in the chest?       

Have you, your child, others accompanying you to today’s appointment or anyone you have recently been in contact with tested positive for or been diagnosed as having COVID-19 or any other communicable disease?                             

If yes, provide approximate dates of illness.
 Symptom start date: 

  Symptom end date 

I understand that if the answer to any of these questions is yes, I will be asked to reschedule my orthodontic appointment to a later date.


Patient/Parent/Guardian Signature: