Supplemental Health Questionnaire - Curtis & Barysenka Orthodontics

Name*

First Last

Email*

Please enter your email, so we can follow up with you.

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
No

A Fever (defined as above 99.6 degrees)*

Yes
No

What is your actual temperature?*

A Cough?*

Yes
No

Shortness of Breath and/or Trouble Breathing?*

Yes
No

Persistent Pain, Pressure, or Tightness in the Chest?*

Yes
No

Did you or your child travel outside the State of Illinois in the last 14 days.*

Yes
No

**If you traveled to any of the states listed on the current Chicago Emergency Travel Order as a state experiencing a surge in new COVID-19 cases, we would ask you to reschedule your appointment at least 14 days after your return date.

I understand that if the answer to any of these questions is yes, I will be asked to reschedule today’s orthodontic appointment.*

I agree.

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