Covid-19 Screening Form

Patient First Name:
Patient Last Name:

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:

* In the last 10 days, have you, your child or other close contacts (family members or acquaintances) had any of the following:
  • Positive or suspected diagnosis of COVID-19
  • A fever greater than 99.6 degrees
  • A cough
  • Shortness of breath and/ or difficulty breathing
  • Persistent pain, pressure or tightness in the chest

Please contact our office at (614) 389-8346 if you have answered yes to any of the questions to determine if rescheduling your orthodontic appointment is appropriate.

Parent/Patient E-Signature: