Health Questionnaire Patient's Name * Enter your full name E-mail * Enter a valid email Parent/Guardian Name (If Patient is a Minor) Parent/Guardian Email (If Patient is a Minor) Make of Vehicle* Vehicle Model* 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?YesNo If yes, when? Do you have a fever (defined as above 99.6 degrees)?YesNo What is your actual temperature? Do you have a cough?YesNo Do you have shortness of breath and/or trouble breathing?YesNo Do you have persistent pain, pressure, or tightness in the chest?YesNo I understand that if the answer to any of these questions is yes, I will be asked to reschedule today’s orthodontic appointment.I agreePlease contact me Additional information