Dear Roeder Orthodontics Patients, Parents and/or Guardians, Due to the COVID-19 pandemic, it has become necessary that we ask all parents/patients to complete the following questionnaire: Has the patient or anyone in their household traveled outside of the country or state in the last 90 days?* Yes No Has the patient or anyone in the patient's household, come into contact with anyone who may have tested positive for COVID-19 within the last 30 days?* Yes No Has the patient or anyone in the patient's household recently had, or currently have, a sore throat?* Yes No Has the patient or anyone in the patient's household recently had, or currently have, a cough?* Yes No Has the patient or anyone in the patient's household recently had, or currently have, a fever of more than 100 degrees?* Yes No Is the patient or anyone in the patient's household feeling ill, in any way?* Yes No Is today's patient experiencing an orthodontic emergency?* Yes No Today's Temp* Time Taken* We do understand the concern regarding the current COVID-19 status. We here at Roeder Orthodontics are dedicated to providing a clean and sanitary environment to ensure the health and safety of all patients and staff, alike. It is our goal to provide all Roeder Orthodontics patients the ability to receive their orthodontic care, in light of the current outbreak. By signing below, you acknowledge that the treatment being provided during this time is completely voluntary and the patient does not have emergent needs.Patient Name* First Last Patient/Parent/Guardian Name* First Last Please sign by typing your Full Name **
