COVID-19 Health Form

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?

Please select symptoms on if they are a change from what is normal for you.

Cough
Congestion or Running Nose
Chills
Headache
Muscle Pain
Sore Throat
Loss of Taste or Smell
Digestive Problems

Is your temperature above 99.9 degree Fahrenheit?

Yes
No

Have you been in close contact with someone who tested positive for COVID in the past 10 days AND has NOT REPORTED this to the poly COVID safety team.

Close contact is defined as being within 6 feet of an infected person for a total of 10 min or more. Fully vaccinated people who are asymptomatic do not have to quarantine but must test 3-5 days after exposure and wear a mask for 14 days.

Yes
No

Have you been diagnosed with COVID-19 within the past 10 days?

Yes
No

Have you recently traveled in from abroad?

Yes
No

Have you recently traveled in from a state experiencing increased Covid-19 cases?

Yes
No

Have you traveled to another state within the last 14 days?

Yes
No

State

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's First Name

Patient's Last Name

Email

Patient/Parent’s Signature

Date

Covid-19 Health Form

Covid-19 Health Form