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:
Have you, your child, or others accompanying you to today’s appointment or other recent acquaintances tested positive for or been diagnosed as having COVID-19 or any other communicable disease? YesNo
If yes, when?
Do you, your child, or others accompanying you to today’s appointment or other recent acquaintances have:
- A Fever (defined as above 99.6 degrees) YesNo
- A Cough? YesNo
- Shortness of Breath and/or Trouble Breathing? YesNo
- Persistent Pain, Pressure, or Tightness in the Chest? YesNo
- Any other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue? YesNo
- Have you/they experienced a recent loss of taste or smell? YesNo
- Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location) YesNo
I understand that all my answers are to the best of my knowledge and I may be asked to reschedule today's appointment one of my answers is yes.
Patient/Parent’s Signature
Date
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