Supplemental Health Questionnaire

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?

 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
If yes provide approximate dates of illness
 Yes

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