Supplemental Informed Consent and Health Questionnaire for COVID-19 from Lehnes Orthodontics

AAO Supplemental Informed 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 No
Patient Name *
Parent/Guardian Name (if applicable) *
Relation *
Patient/Parent/Guardian Signature *

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Date *

Month Day Year
Used with the permission of the American Association of Orthodontists

Travel Questionairre
Have you, your child, or others accompanying you to today's appointment traveled outside of New Jersey by car, air, bus or train within the last 14-21 days? *

Yes No
If you answered yes to the above question, please provide the state and dates traveled. If the answer is no, please type N/A below. *
Have you, your child, or others accompanying you to today's appointment traveled outside of the United States by air, bus or train within the last 14-21 days? *

Yes No
If you answered yes to the above question, please provide the country and dates traveled. If the answer is no, please type N/A below. *
Patient Name *
Parent/Guardian Name (if applicable) *
Relation *
Date *

Month Day Year
Date
Patient/Parent/Guardian Signature *

use cursor or finger to sign Clear
By clicking the "Submit Form" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
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Supplemental Informed Consent and Health and Travel Questionnaire for COVID-19