Supplemental Health Questionnaire

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Supplemental Health Questionnaire

If you have been exposed to a communicable disease, such as COVID-19, 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.

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* Indicates required question

Patient(s) Name(s) *

Your answer

Has everyone attending your appointment been fully vaccinated against COVID-19 (If no, you will proceed to the next section. If yes, you will have completed the questionnaire) *

Choose

Yes

No

Decline to Answer

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