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COVID-19 Patient 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 practitioner, orthodontic staff, or other patients/parents in the practice. Therefore, prior to each appointment, we will be asking for you to complete this screening form for you, or your child,


How would you describe your health / symptoms?
SymptomsPlease check off any symptoms you are experiencing.







Patient Signature: By typing out your name below you acknowledge that you have answered all questions honestly and to the best of your ability. Additionally,  you understand that if the answer to any of these questions was yes, you may be asked to reschedule the orthodontic
appointment to a later date.

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