Patient Health Screening Form

As we prioritize the health and safety of our patients and staff, we kindly request you to complete the COVID-19 Patient Health Screening Form. Your cooperation in filling out this form will help us stay informed about any potential interactions you may have had with COVID-19, enabling us to take necessary precautions and provide a secure environment for everyone.

At Shakespeare Orthodontics, we understand the importance of thorough health screening, especially during these times. This form is designed to gather essential information that allows us to assess potential risks and implement necessary measures to ensure the well-being of our orthodontic community.

Please take a moment to provide accurate details regarding any recent interactions, symptoms, or exposure to COVID-19. Rest assured that all information shared is treated with the utmost confidentiality and used solely for health and safety purposes.

Your proactive participation in completing this form demonstrates your commitment to maintaining a healthy and secure orthodontic environment. We appreciate your cooperation and look forward to continuing to provide exceptional orthodontic care while prioritizing the health and safety of everyone in our community.