COVID-19 Screening Form
To ensure that we maintain a safe environment for our patients and team members, please take a few minutes prior to your appointment to answer the following questions.

Your safety and well-being is our number one priority!

Thank you! <3
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Do any of the following apply to you or anyone you have recently been in contact with today or over the last 14 days? *
Yes
No
Fever above 99.6 degrees
Cough
Shortness of breath and/or trouble breathing
Pesistent pain, pressure, or tightness in the chest
Flu-like symptoms, such as gastrointestinal upset, headache or fatigue
Recent loss of taste or smell
Tested posotive for COVID-19
Please select which applies to you: *
I understand that if the answer to any of the questions above is yes, I may be asked to reschedule today's orthodontic appointment to a later date to ensure the safety and health of all patients and team members. *
Please enter first & last name
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This form was created inside of Bellevue Orthodontics.