COVID-19 Supplemental Health Questionnaire

If you have been exposed to a communicable disease, you may spread the disease to the orthodontist, orthodontic staff, or other patients/parents 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?
Fever (defined as above 99.6 degrees)?(Required)
Shortness of breath and/or trouble breathing?(Required)
Persistent pain, pressure, or tightness In the chest?(Required)
Have you, your child, others accompanying you to today's appointment or anyone you have recently been In contact with tested positive for or been diagnosed as having COVID-19 or any other communicable disease?(Required)
I understand that if the answer to any of these questions is yes, I may be asked to reschedule today's orthodontic appointment to a later date.(Required)
Patient Name(Required)
Parent Guardian Name (if applicable)
Please type name
MM slash DD slash YYYY

We hope this message finds you and your family in good health. We missed you and your family’s smiles! Our community has been through a lot over the last few months, and all of us are looking forward to resuming our normal life and routines. While many things have changed, one thing has remained the same: our commitment to your safety and health.

Our office follows infection control recommendations made by the American Dental Association (ADA), the U.S. Centers for Disease Control and Prevention (CDC) and Massachusetts Dental Society (MDS). We follow the activities of these agencies so that we are up-to-date on any new rules or guidance that may be issued. We do this to make sure that our infection control procedures are current and adhere to each agencies’ recommendations.

You may see some interim changes for at least the next couple months when it is time for your next appointment. Our goal is to ensure your ultimate safety during your visit with us.

Additional forms to be signed before your visit

Please complete the health questionnaire before your appointment. It can be found and signed directly on our website (above). If you answer “yes” to any question on the questionnaire, please reschedule your appointment.

Relaxed Schedule

We’ll be changing the way we schedule appointments to help maintain social distancing requirements. To make sure there are fewer people in the office at the same time, we’ll schedule fewer appointments throughout the day, and we are planning to add additional hours and days to our weekly regular hours to ensure seeing all our patients to minimize any delay or inconvenience.

Curbside Drop-off and Check in

We ask for the companion to wait from the safety of your car. Whenever possible, patients should enter the office alone. If you stay in the car during your teen’s appointment, a staff member will call you to discuss the appointment.

Health screening upon arrival

We’ll take your temperature as soon as you enter our office. We’ll also ask you to complete a health screening questionnaire before starting your appointment. If you answer “yes” to any question on the questionnaire, we’ll ask you to reschedule your appointment. Everyone entering the office should wear a mask or face covering.

No extra people in the office

We won’t allow more than one person in the office with young patients or patients with special needs or considerations. Older patients should attend their appointments alone. We may ask the parent to wait in the reception area instead of coming into the treatment area.

Brush your teeth before you arrive

Our tooth brushing stations will be closed, so make sure your teeth are sparkling clean before you come.

We’ll be taking these additional steps to keep our office safe

  • At check in, please remain behind the safe guard to ensure your and our front desk safety.
  • All team members will wear masks at all times and gloves/ face shields when necessary.
  • All surfaces will be disinfected thoroughly during the day, and the whole office will be sprayed with Disinfectant after each clinical session.
  • 6 ft. social distancing will be strictly enforced
  • Doors will remain open when possible to reduce shared surface contact.
  • Toys, coffee, and magazines have been removed from all waiting areas.
  • All team members will complete a health screening and have their temperature taken when they arrive.
  • Team members with any symptoms will be asked to stay home.

Reschedule If You’re Sick

Please reschedule your appointment if anyone in your family is experiencing any of the following symptoms, or if you’ve come in contact with anyone who has tested positive for COVID-19.

  • Fever
  • Cough
  • Shortness of breath or difficulty breathing
  • Repeated shaking and/or chills
  • Muscle pain
  • Headache
  • Sore throat
  • New loss of taste or smell

Thank you for your understanding and patience with us during this challenging time. We value your trust and loyalty and look forward to welcoming back you, your friends and family.

Dr. Salem and team