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 legal first and last name: *
Has the patient or anyone accompanying : *
Tested positive for COVID-19?
Been in contact with someone who has tested positive or has shown symptoms?
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
Patient/Guardian Signature and Date *
Would you like a phone call update for your child's appointment?
Clear selection
Please take the time to watch our video of our COVID-19 protocols before your appointment. Thank you!
Never submit passwords through Google Forms.
This form was created inside of Jacobson & Tsou Orthodontics. Report Abuse