COVID-19 Health Questionnaire and Consent

Orthodontic Treatment in the Era of COVID-19

We appreciate you taking a moment to complete this COVID Questionnaire and Consent before each appointment. Thank you!
Today's Date *

Month Day Year
Patient Name *

First Name Last Name
Patient Date of Birth *

Month Day Year
Date
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 100.4° F degrees)? *

Yes No
Is the patient having shortness of breath or other difficulties breathing? *

Yes No
Does the patient have a cough? *

Yes No
Does the patient have any flu-like symptoms, such as gastrointestinal upset, headache or fatigue? *

Yes No
Has the patient experienced recent loss of taste or smell? *

Yes No
Has the patient been in contact with any confirmed COVID-19 positive patients? *

Yes No
Does the patient have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? *

Yes No
Has the patient traveled into or outside of Hawaii in the past 14 days? *

Yes No
*** If the patient has travelled into or outside of Hawaii in the past 14 days, by signing below, you affirm that the patient had a negative COVID test result upon arrival to Hawaii. ***
If you answered yes to any of the above, please explain:
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.
Consent:

Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as "Coronavirus", at any time or in any place. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so.

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.
Although exposure is unlikely, do you accept the risk and consent to treatment? *

Yes, I consent to treatment No, I do NOT consent to treatment
New Office Protocols Regarding COVID-19

To minimize crowding in our office and to comply with social distancing guidelines, we kindly ask that you come to your appointment alone. If you are bringing your child to their appointment, we are asking that all family members, parents/guardians and or other guests wait in the car during the appointment. Our reception area is only open to scheduled patients. We will ask that ONLY the patient comes into the office unless any of the following applies:
- If the patient is a child and it is their initial consultation appointment, ONE parent may accompany him/her at this visit.
- The patient has special needs.
- It is requested by one of our staff members that a parent/guardian come into our office to sign paperwork/documents.
To parents/guardians - should you have any questions or concerns that we may address at your child’s appointment, please call our office upon arrival and let us know. When the appointment is done, your child will be escorted to the car by a staff member and you will be briefed on their visit. To schedule their next appointment, you may call our office or request that one of our receptionists contact you.

These are challenging times and we are constantly adjusting our approach to keep our patients and our team safe. Also, please remember to wear a mask to your appointment. We thank you again for your understanding and patience.

Caswell Orthodontics
Patient/Parent/Guardian Signature *

Clear
Should be Empty:

Orthodontic Treatment in the Era of COVID-19