Covid - 19 Health Form | John Orrthodontics

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 degrees)?

Yes
No

Cough?

Yes
No

Shortness of breath and/or trouble breathing?

Yes
No

Persistent pain, pressure, or tightness in the chest?

Yes
No

Have 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?

Yes
No

If yes provide approximate dates of illness

Consent

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/Parent’s Name

First Last

Email

Patient/Parent’s Signature

Date

Solve (12*8)*

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

Book With Us Today!

free consultation

get directions

Book With Us Today!

free consultation

get directions

Covid-19 Health Form

Email Us

Free Consultation

Office Hours