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:
Do you, your child, or others accompanying you to today’s appointment or anyone you have recently
been in contact with have any of the following symptoms?
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?
I understand that if the answer to any of these questions is yes, I will be asked to reschedule
today’s orthodontic appointment.