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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, others accompanying you to today’s appointment or anyone you have recently been in contact with have any of the following symptoms?

symptom start date
symptom end date
(if applicable)

Patient/Parent/Guardian Signature

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