Wellness Screening & Treatment Consent
To our orthodontic family and friends,

Thank you for your support and patience in the past weeks as our office has been closed due to the COVID-19 pandemic. We are very much looking forward to resuming orthodontic care in the safest possible way for both patients and staff. Part of that initiative includes the attached Wellness Screening and Treatment Consent that we request to be returned prior to EACH APPOINTMENT. Please call or email the office if you have any questions. Thank you.
Email address *
Today's Date *
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Name *
Patient name (if different)
Prior to the appointment, *
Yes
No
have you had anything hot or cold ?
have you taken Tylenol or Ibuprofen?
In the last 14 days, has the patient (or any member of the household) had any of the following? *
Yes
No
Fever (Over 38'C)
New onset of Cough or worsening chronic cough
Shortness of Breath/Difficulty Breathing
Sore throat/difficulty swallowing
Loss of taste or smell
Chills
Any other flu-like symptoms, such as gastrointestinal upset, nausea/vomiting, diarrhea, headache 
or fatigue?
Traveled out side of the country
Pink eye (conjunctivitis)
Runny nose/nasal congestion without other known cause
Has the patient, a family member, or any known close contact had either of the following occur? *
Yes
No
Diagnosis of COVID-19 infection, or any other communicable disease
Waiting on results of test for COVID-19 infection
Been in the close contact with someone who has been diagnosed with or is under investigation of COVID-19
If the patient, family member or close contact has been diagnosed with COVID-19 infection, when did that occur?
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*
Yes
No
Are you age over 65?
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
If the answer is yes to any of the previous questions, I understand I will be asked to reschedule today's appointment. *
If you found out that you are COVID-19 positive after today’s visit, please notify us ASAP as the clinic needs to report the exposure to all patients treated after the infected patient. *
Treatment Consent: Please be assured that our office has always met or exceeded the requirements set forth for sterilization and infection control from the RCDSO and PHO, and will continue to do so. However, it is possible to contract COVID-19 infection (or any other communicable disease) in any public space. Our office will provide for socially distant appointment scheduling, and also has added a number of new technologies and techniques to the practice to enhance our level of safety. However, due to the nature of the orthodontic treatment, social distance is not possible between the orthodontic patient and clinical staff/doctor. Exposure to communicable diseases is unlikely but possible. Clicking "yes" below indicates that the risks involved are accepted, and that consent is given for treatment to be provided by the office of Dr. Jangyeun Cho and staff. *
Required
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