Hallmark Orthodontics COVID-19 Patient Consent
I knowingly and willingly consent to have orthodontic treatment completed during the COVID-19 pandemic and thereafter. Hallmark Orthodontics is taking every necessary precaution to limit the spread of the disease and is making your health our number one priority. We are following the State and Federal regulations as well as universal personal protection and disinfection protocols to limit transmission of communicable diseases.
I have reviewed the following: *
Required
I confirm that neither my child or myself are presenting with the following symptoms now or within 14 days: *
Required
I confirm that neither my child or myself have traveled outside the United States or domestically by commercial airline, bus, or train within the past 14 days:
Clear selection
Patient Name *
Legal Guardian E-Sign Name (if Minor) *
Date *
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy