Patient Name *

First Name

Last Name

Parent Name

If patient is under the age of 18

First Name

Last Name

Is the patient currently experiencing or has experienced in the last three weeks any of the following symptoms: cough, fever, shortness of breath, and/or loss of taste or smell? *

Yes

No

Has the patient had close contact with an individual diagnosed with COVID-19? *

Yes

No

Have you recently participated in any large gatherings (of more than 250 attendees) or gatherings of people you didn't know? *

Yes

No

Have you or a member of your household traveled outside the United States within the last 14 days? *

Yes

No

I have read and understand the new appointment procedures *

These are found in the COVID Resources tab

I AGREE

By checking this you agree to allow Lafayette Orthodontics to continue orthodontic treatment and are aware of the potential risks of the transmission of COVID-19. The Dr. and Staff are diligently working to minimize the risks of transmission with new social distancing and disinfection protocols. If you have any concerns or preexisting health conditions and would like to postpone your appointment please call our office immediately. Thank you! *

I AGREE