HEALTH QUESTIONNAIRE

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 chances of transmission:

Do you, your child, others accompanying you to today's appointment or anyone you have recently been in contact with have any of the following symptoms?

Fever (defined as above 100.4° F degrees)?

Yes

Cough?

Yes

Shortness of breath and/or trouble breathing?

Yes

Persistent pain, pressure, or tightness in the chest?

Yes

Have you, your child, others accompanying you to today's appointment or anyone you have recently been in contact with tested positive for or been diagnosed as having COVID-19 or any other communicable disease?

Yes

If yes provide approximate dates of illness

I understand that if the answer to any of these questions is yes, I may be asked to reschedule today's orthodontic appointment to a later date. *

Patient Name *

Date of Birth

Parent/Guardian Name (if applicable)

Thanks for submitting!

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Shah Orthodontics

Let Our Family EmBrace Yours

Phone: (760) 244-2005

Fax: (760) 244-8955

braces@shahorthodontics.com

15385 Main St, Ste 102, Hesperia, CA 92345, USA

Accessibility Statement

Serving Hesperia, Oak Hills, Victorville, Apple Valley, Lucerne Valley, Adelanto, Phelan,

Wrightwood, Big Bear, Helendale, Fort Irwin, Pinon Hills and Barstow since 2010

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