• Health Questionnaire

    Prior to each appointment, all patients are required to answer the questions that follow.
  • Date of Appointment*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Who is filling out this form?*
  • Is the patient a minor?*
  • 1. Have you, your child, or others accompanying you to today’s appointment or other recent acquaintances tested positive for or been diagnosed as having COVID-19 or any other communicable disease?*

  • 2. Do you, your child, or others accompanying you to today’s appointment or other recent acquaintances have:

  • A Fever (defined as above 99.6 degrees)*
  • A Cough?*
  • Shortness of Breath and/or Trouble Breathing?*
  • Persistent Pain, Pressure, or Tightness in the Chest?*
  • Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?*
  • 3. Have you experienced recent loss of taste or smell?*
  • 4. Has the individual had contact with people that were infected, suspected or diagnosed with COVID-19?*
  • 5. Have you recently been tested for COVID-19 and are awaiting the test results?*
  • 6. Have you traveled in the past 14 days?*
  • I understand that while exposure to COVID-19 also know as "Coronavirus" during my appointment at Robison Orthodontics is unlikely, I accept the risk and consent to treatment.*
  • Should be Empty: