Greco Orthodontics Updated Health Form

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Email *

Email Address *

Your Name *

Patients Name (if different)

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, others accompanying you to today’s appointment or other recent acquaintances have: *

Yes

A Fever (defined as above 99.6 degrees)

A Cough?

Shortness of Breath and/or trouble breathing?

Persistant pain, pressure or tightness in chest?

Loss of taste or smell?

Diarrhea, vomiting or abdominal pain?

Rash?

Have you or anyone in your household traveled outside of the state in the last 14 days?

I understand that if the answer to any of these questions is yes, I may be asked to reschedule today’s orthodontic appointment. Please sign by typing your Full Name *

Thank you so much and we are truly looking forward to seeing you at your next appointment!

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