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Orthodontists with parent and child My FASTBRACES® of Houston, TX background

Consultation

Request Your Consultation
The First One Is Free!

Schedule a consultation with Dr. Majid Mehrinfar to discuss your orthodontic goals or any questions you may have about our process.


Step 1 out of 2 - Patient Screening:

Patient Name:
Pre-Appointment In Office
Date Date
Do you/they have fever or have you/they felt hot/feverish recently (14-21 days)?
Are you or they having shortness of breath or other difficulties breathing?
Do you or they have a cough?
Any other flu-like symptoms such as gastrointestinal upset, headache or fatigue?
Have you or they experienced recent loss of taste/smell?
Are you/they in contact with any confirmed COVID19 positive patients?
Patients who are well but who have a sick family member at home with COVID19 should consider postponing elective treatment.
Is your/their age over 60?
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Have you or they traveled in the past 14 days to any region affected by COVID19? (as relevant to your location)
YOUR SIGNATURE
Type your full name in CAPITAL letters