COVID-19 Supplemental Health Questionnaire in Lowell, MA

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Orthodontic Treatment in the Era of COVID-19

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 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)?*

Yes
No

Cough?*

Yes
No

Shortness of breath and/or trouble breathing?*

Yes
No

Persistent pain, pressure, or tightness In the chest?*

Yes
No

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?*

Yes
No

If 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

Relation

Patient/ Parent/ Guardian Signature*

Date*

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COVID-19 Supplemental Health Questionnaire

Orthodontic Treatment in the Era of COVID-19

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