INDIGO Orthodontics COVID-19 Screening

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Pre-Orthodontic Treatment Screening and Supplemental Consent
We Request this be returned prior to EACH APPOINTMENT.

Email *

Patient Name *

Date *

YYYY

Thank you for your continued trust in our team and our practice! As always, the safety and health of our patient families and team members are of the highest priority. Please be assured in knowing that we have always all guidelines and regulations regarding Universal personal protection and disinfection protocols to limit the transmission of all diseases in our office, including COVID-19. This screening is a part of our effort to provide the safest possible environment for our patients and our team. Kindly complete this screening questionnaire before each office visit.

Have you, your child or others accompanying you to today’s appointment tested positive for COVID in the last 14 days *

Yes

Had a fever above 100.4F *

Yes

Have/had a Cough recently *

Yes

Shortness of Breath and/or Trouble Breathing *

Yes

Loss of Sense of Taste or Smell

Yes

Clear selection

Been in contact with someone tested positive for COVID-19 or awaiting a COVID -19 test result *

Yes

Please note that if the answer to any of these questions is YES, we will gladly assist you in rescheduling your in-office visit. We are available virtually as well.

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