Note: The fields indicated with an asterisk * are required fields.


If you have been exposed to a communicable disease, you may spread the disease to the orthodontist, orthodontist staff, or other patients/parents/family members in the practice.  Therefore, prior to each appointment, we will be asking the following questions to reduce the chances of transmission:

Do you, your child, others accompanying you to today’s appointment or anyone you have recently been in contact with have any of the following symptoms/conditions?

I understand that a positive response to any of these would likely result in a deeper discussion before proceeding with elective dental treatment and I may be asked to reschedule the orthodontic appointment to a later date.