COVID-19 Supplemental Health Form

Please fill out the entire questionnaire on the day of any in-office appointment with Cramer Orthodontics. Once complete, click the "Submit Form" button at the bottom, and your information will be submitted using secure encryption.

Patient Information

Items marked with asterisk (*) must be completed.

First Name *	Last Name *

Cell/Other Phone (###-###-####) *	Appointment Date (MM/DD/YYYY) *

Patient Date of Birth (MM/DD/YYYY) *

Supplemental COVID-19 Medical History

Does the patient have a fever or felt hot/feverish (>99.6degrees) in the last 14 days? *
YesNo

Do you/patient currently have a cough or have had one in the last 14 days? *
YesNo

Have you/patient experienced a recent loss of taste or smell? *
YesNo

Has the patient/parent traveled anywhere in the last 14 days considered a COVID-19 "HotSpot"? *
YesNo

Is the patient having shortness of breath or has he/she experienced shortness of breath in the last 14 days? *
YesNo

Any other flu-like symptoms like gastrointestinal upset, headache or fatigue in the last 14 days? *
YesNo

Is the patient in contact with any COVID-19 positive patients? *
YesNo

Orthodontic Treatment in the Era of COVID-19

Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as “Coronavirus,” at any time or in any place. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit the transmission of all diseases in our office and continue to do so. Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be at your gym, grocery store, or favorite restaurant. “Social Distancing” nationwide has reduced the transmission of the Coronavirus. Although we have taken measures to provide social distancing in our practice, due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, orthodontist, orthodontic staff and sometimes other patients at all times.

Although exposure is unlikely, do you accept the risk described above and consent to treatment? * YesNo	Signature (Typing in your full name will act as an electronic signature) *

By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.

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>> Return to COVID-19 Update & Policy page.