Supplemental Health Questionnaire

First Name:
Middle Initial:
Last Name:
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, we are asking each patient the following questions to reduce the chances of transmission.

Have you, your child, others accompanying you to appointments, or those who you have been in recent contact with tested positive for or been diagnosed as having COVID-19 or any other communicable disease?
If yes, date of exposure:
Do you, your child, or others accompanying you to appointments have:
A Fever (defined as above 100.4 degrees)?
A Cough?
Shortness of Breath and/or Trouble Breathing?
Persistent Pain, Pressure, or Tightness in the Chest?
I understand that if the answer to any of these questions is yes, I may be asked to reschedule today’s orthodontic appointment.


**** I agree to verbally confirm these answers at each appointment and notify clinic staff if any of my answers need to be changed prior to my appointment time****

Patient/Parent Signature:
Date: