COVID-19 Screening Form

COVID-19 Screening
If you have been exposed to a communicable disease prior to your orthodontic appointment, you may spread the disease to the orthodontist, orthodontic staff and to other patients/parents in the practice. Therefore, prior to each appointment, we require you to answer the following questions:
Have you, your child, or others accompanying you to today’s appointment been tested positive for or been diagnosed as having Covid-19?*

YesNo
If so, when?

MonthDayYear
Date
Do you, your child, or others accompanying you to today’s appointment have:*

A Fever (defined as above 99.6 degrees)A CoughShortness of Breath and/or Trouble BreathingPersistent pain, pressure or Tightness in the chestNone
Have you experienced loss of taste or smell?*

YesNo
If any of you have any of these symptoms or have recently tested positive for or been diagnosed with Covid-19, you will be asked to reschedule your orthodontic appointment.
COVID-19 Consent
Signature
Patient Name*
Responsible Party
Patient/Responsible Party Email*
example@example.com
Patient/Responsible Party Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

COVID-19 Screening