Fever (defined as above 99.6° degrees)? Fever (defined as above 99.6° degrees)? Yes No

Cough? Cough? Yes No

Shortness of Breath and/or trouble breathing? Shortness of Breath and/or trouble breathing? Yes No

Persistent pain, pressure, or tightness in the chest? Persistent pain, pressure, or tightness in the chest? Yes No

Have you, your child, others accompanying you to today's appointment or anyone you have recently been in contact with tested positive for or have been diagnosed as having COVID-19 or any other communicable disease? Have you, your child, others accompanying you to today's appointment or anyone you have recently been in contact with tested positive for or have been diagnosed as having COVID-19 or any other communicable disease? Yes No

If yes, symptom start date

...and symptom end date.

I understand that if the answer to any of these questions is yes, I may be asked to reschedule today's orthodontic appointment to a later date. I understand that if the answer to any of these questions is yes, I may be asked to reschedule today's orthodontic appointment to a later date. I Understand

Patient Name

Parent / Guardian Name

Relation to Patient

Your Phone Number

Today's Date

Type Your Name to Sign

Although exposure is unlikely, do you accept the risk and consent to treatment? Although exposure is unlikely, do you accept the risk and consent to treatment? Yes No

Patient Name

Parent / Guardian Name

Relation to Patient

Your Phone Number

Today's Date

Type Your Name to Sign

Do you have a fever or have experienced fever within the past 14 days? Do you have a fever or have experienced fever within the past 14 days? Yes No

Have you experienced a recent onset of respiratory problems, such as coughing or difficulty breathing within the past 14 days? Have you experienced a recent onset of respiratory problems, such as coughing or difficulty breathing within the past 14 days? Yes No

Have you, in the past 14 days, travelled to China, Europe or other known hotspot for Corona virus in the US or visited any other area with documented COVID-19 transmissions? Have you, in the past 14 days, travelled to China, Europe or other known hotspot for Corona virus in the US or visited any other area with documented COVID-19 transmissions? Yes No

Have you come into contact with anyone confirmed to be infected with COVID-19 within the past 14 days? Have you come into contact with anyone confirmed to be infected with COVID-19 within the past 14 days? Yes No

Have you come into contact with people who have travelled to China, Europe or other known hotspots for Corona virus in the USA or visited any other area with recent documented cases of people with fever or respiratory problems within the past 14 days? Have you come into contact with people who have travelled to China, Europe or other known hotspots for Corona virus in the USA or visited any other area with recent documented cases of people with fever or respiratory problems within the past 14 days? Yes No

Are there any persons with documented experience of fever or respiratory problems that you have come into contact with, within the last 14 days? Are there any persons with documented experience of fever or respiratory problems that you have come into contact with, within the last 14 days? Yes No

Have you recently participated in any gathering, meetings, or had close contact with people you are not familiar with? Have you recently participated in any gathering, meetings, or had close contact with people you are not familiar with? Yes No

Your Name

Your Body Temperature

Your Phone Number

Today's Date