Supplemental Health Questionnaire Form

Supplemental COVID Questionnaire

To protect you and our Practice, prior to your appointment, we will be asking the following questions to reduce the chances of transmission of COVID - 19:

Have you or your child had any of the following:

A fever (defined as above 99.6 degrees)

Yes No

A cough

Yes No

Shortness of breath and or trouble breathing

Yes No

Chest pain, pressure or tightness

Yes No

Has anyone in the family (or in your acquaintance) tested positive for or been diagnosed as having COVID-19 or any other contagious disease?

Yes No

***I attest these answers to be accurate to the best of my knowledge.

Name of Parent/Patient:

Signature of Parent/Patient:

Date:

By answering these questions, together, we can keep Willowbrook Orthodontics safe for everyone! Please do not hesitate to contact us with any questions concerns you may have regarding in office protocols. We look forward to seeing you soon!