• COVID-19 Screening

    COVID-19 Screening

    If you have been exposed to a virus (COVID-19) prior to your orthodontic appointment, you may spread the virus 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:
  • Have you, your child, or others accompanying you to today’s appointment been tested positive for or been diagnosed as having COVID-19?*
  • Do you, your child, or others accompanying you to today’s appointment have: **
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  • Do you have fever or have you felt hot or feverish recently (14-21 days)?*
  • Are you having shortness of breath or other difficulties breathing?*
  • Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?*
  • Do you have a cough?*
  • Have you experienced recent loss of taste or smell?*
  • Has the patient traveled in the past 14 days?*

  • If any of you have any of these symptoms or have recently tested positive for or been diagnosed with Covid-19, you will be asked to reschedule your orthodontic appointment.

    By signing below, I certify that the above statements are true and correct to the best of my knowledge.

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date submitted*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: