COVID-19 Patient Advisory and Acknowledgment
Patient Name
*
Full legal name
If minor, legal guardian name
Full legal name
Please select "yes" or "no" to the following questions
Do you or anyone accompanying you have a fever?
*
YES
NO
Do you or anyone accompanying you have shortness of breath?
*
YES
NO
Do you or anyone accompanying you have a dry cough?
*
YES
NO
Do you or anyone accompanying you have other flu-like symptoms, including gastrointestinal upset, headache or fatigue?
*
YES
NO
Have you or anyone accompanying you experienced loss of taste and smell?
*
YES
NO
Have you or anyone accompanying you had contact with any confirmed COVID-19 positive people?
*
YES
NO
Within the last 14 days have you or anyone accompanying you travelled to a foreign country?
*
YES
NO
COVID-19 Informed Consent
Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be at your gym, grocery store, or favorite restaurant. “Social Distancing” nationwide has reduced the transmission of the Coronavirus. Although we have taken measures to provide social distancing in our practice, due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, orthodontist, orthodontic staff and sometimes other patients at all times. Do you consent to treatment?
YES
NO
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