COVID-19 Questionnaire


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 100.4° F degrees), chills, cough, sore throat, shortness of breath or trouble breathing, chest pains or tightness, new loss of taste or smell?

Have you, your child, others accompanying you to today’s appointment, or anyone you have recently been in contact with tested positive for (or waiting on a test result) or been diagnosed as having COVID-19 or any other communicable disease?
If yes, provide approximate dates of illness through

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.
Patient First Name:
MI:
Last Name:
Parent/Guardian First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Patient/Parent/Guardian Signature:
Date:
Used with the permission of the American Association of Orthodontists Insurance Company (RRG)