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/conditions?

Fever (defined as above 100.4o F degrees) in the last 21 days ?(Required)
Shortness of breath and/or trouble breathing?(Required)
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?(Required)
Experienced recent loss of taste or smell?(Required)
In contact with any confirmed COVID-19 positive patients?(Required)
Traveled in the past 14 days to a region highly affected by COVID-19?(Required)
I understand that a positive response to any of these questions may result in a deeper discussion before proceeding with elective dental treatment and I may be asked to reschedule the orthodontic appointment to a later date.
Patient Name(Required)
(If applicable)
To finish the process you must put a digital signature or name indicating you have read and agree to the above document.