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HEALTH QUESTIONNAIRE

  • SUPPLEMENTAL

    HEALTH QUESTIONNAIRE

    Orthodontic Treatment in the Era of COVID-19

  • 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?

    If yes provide approximate dates of illness
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY