COVID-19 Consent and Health Questionnaire-Wang Smiles Orthodontics
Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as “Coronavirus,” at any time or in any place. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so.
Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our office. Although exposure is unlikely, do you accept the risk and consent to treatment during COVID-19 pandemic?  *
Have you, your child, or others accompanying you to today’s appointment or other recent acquaintances tested positive for or been diagnosed as having COVID-19 or any other communicable disease? *
Do you, your child, or others accompanying you to today’s appointment or other recent acquaintances have a fever (defined as above 99.6 degrees), cough, shortness of breath/difficulty breathing, or chest pains? *
Patient's Full Name *
Please enter your full name below to certify that you are the responsible party for the patient *
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