Sher Smiles: Supplemental Health Questionnaire

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If you have been exposed to a communicable disease, 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 changes of transmission.

Patient/Parents full name *

Upcoming Appointment Date *

YYYY

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 disease? *

Yes

If yes, when?

Do you, your child, or others accompanying you to today's appointment or other recent acquaintances have: *

Yes

A fever (above 99.6 degrees)?

A cough?

Shortness of breath and/or trouble breathing

Persistent pain, pressure, tightness in the chest?

Please understand that if the answer to any of these questions is yes, we will ask to reschedule today's orthodontic appointment.

Thank you for submitting your response. We look forward to seeing you soon.

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