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Stephenson Orthodontics Updated Health Form
Thank you for putting your trust in our office and we are so glad we are able to see you again.  This form allows us to screen for communicable diseases including COVID-19 in our office in an effort to keep all our patients and team safe. Therefore, prior to each appointment, are required to ask the following questions. We will also be taking temperature for all visitors prior to coming into the office. Before leaving the house for your appointment,  fill out this questionnaire at least 30 minutes prior to your appointment.
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Your Name *
Patient's Name ( If Different) *
Have you, your child, or others accompanying you to today's appointment or other recent acquaintances tested positive for or been diagnosed as having COVID-19 or any other communicable diseases *
If yes, when?
MM
/
DD
/
YYYY
Have you, your child, or others accompanying you  experienced  in the last 14 days : *
Yes
No
A Fever ( Defined as above 37.6 Celsius / 99.6 Fahrenheit )?
A Cough?
Shortness of Breath?
Persistent Pain, Pressure or Tightness in the Chest?
Have you, or anyone with you, been tested for Covid19 and are awaiting the results? *
Have you come into contact with anyone experiencing symptoms of Covid 19 within the last 14 days? *
Are you over the age of 65? *
Do you have any chronic immune or systemic conditions *
I understand that if  answer to any of these questions is a yes, I will be asked to reschedule today's orthodontic appointment, please sign by typing your Full Name *
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