COVID-19 Supplemental Informed Consent/Questionnaire
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.

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.

Prior to each appointment, we require you to answer the following questions:
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? *
Patient's name: *
Has the patient or anyone accompanying : *
Yes
No
Tested positive for COVID-19?
Been in contact with someone who has tested positive or has shown symptoms in the last 14 days?
Experienced any cold or flu-like symptoms in the last 2- 14 days (fever, cough, sore throat, respiratory illness, difficulty breathing, diarrhea, vomiting)?
If yes, please explain
Chicago Travel Quarantine List
The City of Chicago has ordered that everyone traveling from Alabama, Arkansas, Arizona, California, Florida, Georgia, Idaho, Iowa, Kansas, Louisiana, Mississippi, Missouri, Nebraska, Nevada, North Carolina, North Dakota, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Utah and Wisconsin. Has the patient or anyone in household been to those states in the past 14 days? *
Patient/Guardian Signature *
Today's Date *
MM
/
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The CDC and IDPH strongly encourage contact tracing as a method to reduce the community spread of infections. If there is any chance that you or your child may have been positive with Covid-19 during your visit to our office, we would appreciate notification so we can assist in tracing efforts.
Please watch our COVID-19 protocols video before your appointment. Thank you!
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