Covid-19 Health Screening and Consent

Covid-19 Health Screening and Consent

Required for each appointment before entering office
Patient*

First NameLast Name
Has patient had any cold or flu symptoms in the last 7 days or been exposed to anyone with covid-like symptoms in the last 7 days?*

YESNO
Have you been instructed to self-isolate, been in contact with a suspected or positive case of novel coronavirus, or are awaiting test results for a covid test?*

YESNO
If you answered yes to any of the above, please reschedule your visit for 1 week after your symptoms resolve or 1 week after your potential exposure.

(note: this form will not submit if you answer YES - simply call or email to reschedule)
CONSENT I consent to treatment and accept the inherent risks associated with such during the Covid-19 pandemic. I certify that my answers above are truthful and I understand that Dr. Rosang and the team at Island Orthodontics are screening to help protect the patients, the staff, and their families. Office procedures have been modified to help clients maintain social distancing and stay healthy. We ask for your patience as we adapt to the new way of providing care for our patients. We also ask that siblings and friends remain outside or in the car whenever possible to minimize congestion in our office.*

Consent
Signature*

Clear
Parent Name if not patient signature
Should be Empty: