COVID-19 SCREENING

Marshfield Orthodontics

462 Plain Street, Suite 106; Marshfield, MA 02050
Supplemental Health Questionnaire

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?
Patient Name*

First NameLast Name
Fever (defined as above 99.6 degrees)*

YesNo
Cough?*

YesNo
Shortness of breath and/or trouble breathing?*

YesNo
Persistent pain, pressure, or tightness in the chest?*

YesNo
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?*

YesNo
If yes provide approximate dates of illness

MonthDayYear
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.*

I acknowledge the above
Patient/Parent's Signature*

Clear
Date signed*

MonthDayYear
Date
Optional - if you would like a copy of this signed form emailed to you
example@example.com
Should be Empty: