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Supplemental Health Questionnaire

Orthodontic Treatment in the Era of COVID-19

Must be completed ON scheduled appointment day

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

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.

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