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. Please complete your form prior to your appointment.
Patient Name *

First Name Last Name
Date

Month Day Year
Date

Do you, your child, others accompanying you today or anyone else you have recently been in contact with have any of the following symptoms? *

Yes

No

Fever (defined as above 100.4 degrees F)

Chills

Cough

Sore Throat

Shortness of breath and/or trouble breathing

Persisten muscle pain, pressure or tightness in the chest

New loss of taste or smell

Have you or others accompanying you to today's appointment traveled outside of our local area or outside of the US within the past 14 days? *

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
AUTHORIZATION

I have read and I understand the questions above. To my knowledge, the above information is correct. I understand that if the answer to any of these questions is yes, I may be asked to reschedule today’s orthodontic appointment. I agree to notify the dental practice if within 14 days I become ill with COVID-19 symptoms or test positive for COVID-19.
Signature

Clear
Should be Empty:

stop the spread of germs

Additional resources

For more information about what you can do to prevent the spread of COVID-19, please visit the World Health Organization website.

You can visit the California Department of Health website to see the latest updates on COVID-19 in California.

ReadySLO.org is a great resource for the most up to date information on COVID-19 in SLO county.