COVID-19 Questionnaire

Patient Name*

Email*

Phone*

Date of Birth*

Has there been any changes to the following:

Patient's health history?*
YesNo

Patient's dental insurance?*
YesNo

Patient's contact information?*
YesNo

PATIENT ADVISORY AND ACKNOWLEDGMENT REGARDING RECEIVING ORTHODONTIC/DENTAL TREATMENT DURING THE COVID-19 PANDEMIC

At our office, your safety is our top priority. We want to assure you that while many things have changed, one thing remains the same, our unwavering commitment to patient safety to ensure you are both, safe and comfortable.

Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge.

Therefore, we ask that you answer a number of “screening” questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.

Have you, your child, or members of your household tested positive for, or been diagnosed as having COVID-19?*
YesNo

[group covid-19-yes]

If yes, who and when?

[/group]

Parent/Guardian/Self Signature

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