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*

MonthDayYear
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
COVID-19 MASK MANDATE UPDATE

Dear Patients,

Our top priority is the health and safety of our staff, patients and community.

As you probably have heard, Governor Ige just announced that he will drop the statewide indoor mask mandate, effective 11:59PM on Friday, March 25. However, businesses, including health care facilities, may require their customers/clients/patients to continue wearing masks indoors.

At Caswell Orthodontics, we will continue to require masks in our offices. Screening protocols such as temperature checks and our COVID screening questionnaire will also still be required prior to each appointment.

We will continue to assess our safety measures and will keep patients informed of any future changes. Thank you for your cooperation and understanding while we continue to keep everyone healthy as we move through the next era of the pandemic.

Thank you,

Caswell Orthodontics
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 have any of the following symptoms?
Fever, cough, shortness of breath and/or difficulty breathing?*

YesNo
Does the patient have any flu-like symptoms, such as gastrointestinal upset, headache or fatigue?*

YesNo
Has the patient experienced recent loss of taste or smell?*

YesNo
Has the patient been in close contact with anyone diagnosed with COVID-19?*

YesNo
Does the patient have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*

YesNo
If you answered yes to any of the above, please explain below.
If you have a fever, shortness of breath, cough, loss of taste or smell or flu-like symptoms - please DO NOT complete this screening form and call the office to cancel or reschedule your appointment.
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
Patient/Parent/Guardian Signature*

Clear
Should be Empty:

Orthodontic Treatment in the Era of COVID-19