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?*YesNoA Fever (defined as above 99.6 degrees)*YesNoWhat is your actual temperature?*A Cough?*YesNoShortness of Breath and/or Trouble Breathing?*YesNoPersistent Pain, Pressure, or Tightness in the Chest?*YesNoI understand that if the answer to any of these questions is yes, I will be asked to reschedule today’s orthodontic appointment.* I agree. Message*CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.