Wellness Screening and 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 in compliance with our Governor's directives during the peak of the COVID-19 pandemic. We are very much looking forward to resuming orthodontic care in the safest possible way for both patients and our team. Part of that initiative includes the attached Wellness Screening and Treatment Consent that we request is returned prior to EACH APPOINTMENT. Please call or email the office if you have any questions, and we will see you soon! =)
Patient Name *
Your answer
Parent Name
Your answer
Email *
Your answer
Phone number *
Your answer
In the last 14 days, has the patient or any member of the household had any of the following? *
Yes
No
Fever (over 99.6 degrees F)
Coughing
Shortness of breath or difficulty breathing
Persistent pain, pressure or tightness in chest
Loss of sense of smell
Travel by airplane or cruise to known COVID-19 areas
Participated in any large gatherings (of more than 10 attendees) or gatherings of people you didn't know
Come in close contact (within 6 feet) with someone who has had a laboratory-confirmed COVID-19 diagnosis
Does the patient or anyone living at home come into close contact with COVID-19 positive patients in the work place? *
Has the patient, a family member, or any known close contact had any 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
Symptomatic, but unable to get tested for COVID-19
If the patient, family member, or close contact has been diagnosed with COVID-19 infection, when did it occur?
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DD
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YYYY
How many negative COVID-19 tests has the patient, family member or close contact tested?
When was the last negative COVID-19 test?
MM
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DD
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YYYY
When was the last date of symptoms?
MM
/
DD
/
YYYY
If the answer to any of these questions changes before the appointment, I agree to notify Dr. Woo and Dr. Polan's office as soon as possible. Also, if the answer is yes to any of the previous questions, I understand I will be asked to reschedule the appointment. *
Treatment Consent: Please be assured that our office has always met or exceeded the requirements set forth for sterilization and infection control from the CDC and OSHA, and will continue to do so. However, it is possible to contract COVID-19 infection (or any other communicable disease) in any public space. We will also provide for socially distant appointment scheduling. However, due to the nature of orthodontic treatment, a 6 foot distance is not possible between the orthodontic patient and clinical staff/doctor. Re-entering public life comes with some risks that we all must weigh, but we also want you to feel confident that our office is taking every step to keep our patients and staff safe during this difficult time. Clicking "yes" below indicates that the risks involved are accepted, and that consent is given for treatment to be provided by Riverdale and Tuckahoe Family Orthodontics. *
Comments
Your answer
I, the patient or the legal guardian of patient's named above, acknowledge that the information I have provided above is true to the best of my knowledge. Please type your name below. *
Your answer
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