Select a location:

COVID-19 Screening Form

Covid-19 Screening Form

  • Prettyman Orthodontics logo
  • - Fever above 100.4 degrees
    - Fatigue and body aches
    - Shortness of breath
    - Nausea/vomiting
    - Cough
    - Runny nose
    - Sore Throat
    - Loss of taste or smell
  • Reset signature Signature locked. Reset to sign again
  • **If the signature field fails to load, try to refresh the page. If that doesn't resolve the issue, please try another browser and retry and submit this form again**

  • MM slash DD slash YYYY