AAOIC SUPPLEMENTAL HEALTH QUESTIONNAIRE
If you have been exposed to a communicable virus, you may spread the virus to the orthodontist, the 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:
Have you, your child, anyone in your household or other recent acquaintances tested positive for or been diagnosed as having COVID-19 or any other communicable disease?
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Yes
No
Do you, your child, anyone in your household or other recent acquaintances have:
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Yes
No
A fever (99.9 degrees or above)
A cough
Shortness of breath
Tightness in the chest
Sore throat
Parent / Patient Signature
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Clear
Date
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/
Month
/
Day
Year
Date
AAOIC 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 at any time or place. Be assured that we have always followed state and federal regulations & recommended universal personal protection and disinfection protocols to limit transmission of all diseases 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 grocery store, gym, workplace or favorite restaurant. “Social Distancing” nationwide has reduced the transmission of COVID-19. 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 due to the extra precautions we will be taking in our office, do you accept the risk and consent to treatment?
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Yes
No
Patient / Parent Signature
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Clear
Date
*
/
Month
/
Day
Year
Date
Submit
Should be Empty: