Greater Madison Orthodontics Patient Advisory and Acknowledgment: Receiving Orthodontic Treatment During the COVID-19 Pandemic
We comply with Wisconsin Department of Health Services and the CDC infection control guidelines to help prevent the spread of the COVID-19 virus. Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. Other patients entering this facility are also symptom-free and claim to not have been in contact with any known infected person for the past 14 days. Risk factors for complications with COVID-19 per the CDC.

If any of these apply to you, consider delaying treatment
• 65 years and older
• Chronic lung disease or moderate to severe asthma
• Serious heart conditions
• Immunocompromised-includes cancer treatment, smoking, bone marrow or organ transplantation, immune
deficiencies, poorly controlled HIV or AIDS, and prolonged use of corticosteroids and other immune
weakening medications.
• Severe obesity (body mass index [BMI] of 40 or higher)
• Diabetes
• Chronic kidney disease undergoing dialysis
• Liver disease

In order to reduce the risk of spreading COVID-19, we need you to answer several “screening” questions in the next section. If you answer yes to any of these questions, please CALL TO RESCHEDULE your appointment.
Sign in to Google to save your progress. Learn more
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy