AAOIC 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:


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/Parent/Guardian Signature: