COVID-19 Supplemental Health Questionnaire Form

COVID-19 Supplemental Health Questionnaire Form
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/conditions?
Fever (defined as above 100.4 F Degrees) in the last 21 days?*

YesNo
Shortness of breath and/or trouble breathing?*

YesNo
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?*

YesNo
Experienced recent loss of taste or smell?*

YesNo
In contact with any confirmed COVID-19 positive patients?*

YesNo
Traveled in the past 14 days to a region highly affected by COVID-19?*

YesNo
I understand that a positive response to any of these questions may result in a deeper discussion before proceeding with elective dental treatment and I may be asked to reschedule the orthodontic appointment to a later date.
Patient Name*

First NameLast Name
Email*
example@example.com
Parent/Guardian Name (if applicable)

First NameLast Name
To finish the process you must put a digital signature or name indicating you have read and agree to the above document.
Signer Name*

First NameLast Name
Signature*

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