My Practice Orthodontics

Patient's Name

Has the patient experienced any of the following symptoms in the past 48 hours:

• fever or chills • cough • shortness of breath or difficulty breathing • fatigue • muscle or body aches • headache • new loss of taste or smell • sore throat • congestion or runny nose • nausea or vomiting • diarrhea

OR

In the past 14 days, has the patient been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with: Anyone who is known to have laboratory-confirmed COVID-19 **OR** anyone who has any symptoms consistent with COVID-19?

OR

Is the patient isolating or quarantining due to an exposure to a person with COVID-19 or is the patient worried they may be sick with COVID-19?

OR

Is the patient currently waiting on the results of a COVID-19 test?

Have you answered Yes to any of the above questions?

Yes

No

Responsible Party/Guardian First & Last Name

Mobile Phone

Email

Preferred Communication Method

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