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NOTE: This form must be completed the same day, or no more than 24 hours prior to, the patient's appointment time.

COVID-19 Health Questionnaire

With community transmission of communicable diseases, you could be exposed anywhere to infectious diseases including, but not limited to Covid-19 (also called Coronavirus). Our orthodontic office is following the State and Federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of communicable diseases. However, it is possible that these precautions will not always be successful in blocking the transmission of these diseases. Social distancing nationwide has reduced the transmission of Covid-19, however it is not possible to provide orthodontic treatment with social distancing between the patient, orthodontist, orthodontic staff and sometimes, other patients. By presenting yourself or your child for orthodontic treatment, you assume and accept the risk that you or your child may inadvertently be exposed to a communicable disease.

If you have been exposed to a communicable disease prior to your orthodontic appointment, you may spread the disease to the orthodontist, orthodontic staff and to other patients/parents in the practice. Therefore, prior to each appointment, we require you to answer the following questions:

Have you, your child, or others accompanying you to today’s appointment been tested positive for or been diagnosed as having Covid-19? YesNo

If yes, when?

Select Today’s Date if “No”

What is the Fahrenheit temperature of the patient today?

Do you, your child, or others accompanying you to today's appointment have:

A fever?

Yes

A cough?

Yes

Shortness of breath and/or trouble breathing?

Yes

Persistent pain, pressure or tightness in the chest?

Yes

If any of you have any of these symptoms or have recently tested positive for or been diagnosed with Covid-19, you will be asked to reschedule your orthodontic appointment.

Do you acknowledge and accept the risk of exposure in our orthodontic office to a communicable disease, included but not limited to Covid-19, and consent to treatment?

Yes

Patient's name if different from who is signing below (typically a minor or dependent)

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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April 27, 2020 9:13 pm MST

COVID-19 Health Questionnaire Uploaded by Won-Woo Park - forms@ooliortho.com IP 70.184.77.29

April 28, 2020 4:09 pm MST

OoLi Forms Archive - forms@ooliortho.com added by Won-Woo Park - forms@ooliortho.com as a CC'd Recipient Ip: 68.2.80.174

April 28, 2020 5:58 pm MST