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 full name: *
If you would you like an update from the Doctor about your child's appointment you must be present in the office. Would you like an update? *
Has the patient or anyone accompanying : *
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
Has the patient or anyone in household been OUT of the state of Illinois in the past 10 days? *
Never submit passwords through Google Forms.
This form was created inside of Jacobson & Tsou Orthodontics. Report Abuse