COVID-19 Supplemental Health Questionnaire Orthodontic Treatment in the Era of COVID-19If 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 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)?*YesNoCough?*YesNoShortness of breath and/or trouble breathing?*YesNoPersistent pain, pressure, or tightness In the chest?*YesNoHave 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?*YesNoIf yes provide approximate dates of illness (START DATE)Through (END DATE) I understand that if the answer to any of these questions is yes, I may be asked to reschedule today's orthodontic appointment to a later date. Patient Name* First Last Parent Guardian Name (if applicable) First Last RelationPatient/ Parent/ Guardian Signature*Date* Date Format: MM slash DD slash YYYY CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
