SUPPLEMENTALHEALTH QUESTIONNAIREOrthodontic Treatment in the Era of COVID-19If 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 99.6 degrees)? Cough?*YesNoCough?*YesNoShortness of breath and/or trouble breathing?*YesNoPersistent pain, pressure, or tightness in the chest?*YesNoHave you, your child, others accompanying you to today's appointment or anyone you have recently been in contact with tested positive for or been diagnosed as having COVID•19 or any other communicable disease?*YesNoIf yes provide approximate dates of illnesssymptom start date Date Format: MM slash DD slash YYYY symptom end date Date Format: MM slash DD slash YYYY 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 Name*Parent/Guardian Name (if applicable)RelationPatient/Parent/Guardian Signature*Date* Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.
