COVID Consent Form
Please fill out this form prior to your orthodontic appointment
Name
*
First Name
Middle Name
Last Name
Age
Email
*
example@example.com
Appointment Date
*
-
Month
-
Day
Year
Date
Have you travelled outside of the Northern Ontario Region within the last 14 days?
*
Yes
No
Please specify
*
Are you currently waiting on the results of a COVID-19 test?
*
Yes
No
Are you currently a part of class cohort or a school shutdown due to COVID-19?
Yes
No
Did the patient have close contact with anyone with acute respiratory illness or traveled outside of Ontario in the last 14 days?
*
Yes
No
Does the patient have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?
*
Yes
No
Do you have any of the following symptoms?
*
Fever
New Onset Of Cough
Worsening Chronic Cough
Shortness Of Breath
Difficulty Breathing
Sore Throat
Difficulty Swallowing
Decrease Or Loss Of Sense Of Taste
Decrease Or Loss Of Sense Of Smell
Chills
Headaches
Unexplained Fatigue
Muscle Aches
Nausea / Vomiting
Diarrhea
Abdominal Pain
Pink Eye
Runny Nose
Nasal Congestion
None Of The Above
Are you above 70 years of age?
Yes
No
Are you experiencing any of the following symptoms?
Delirium
Unexplained Or Increased Number Of Falls
Acute Functional Decline
Worsening Chronic Conditions
If you experience any of the above symptoms prior to scheduled appointment and after this form is submitted, I agree to notify Dr David D'Aloisio's office as soon as possible in order to keep his staff and other patient's safe. I understand that my appointment will be rescheduled as a result or will be changed into virtual appointment.
*
I Understand
Any Comments:-
I, the patient or the legal guardian of the minor patient named above, acknowledge that the information I have provided is true to the best of my knowledge.
*
I Understand
Signature
*
Name
*
First Name
Middle Name
Last Name
Date
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Print
Save
Submit
Should be Empty: