Florian Orthodontics - Wellness Screening and Treatment Consent
We would like to express our gratitude for your flexibility and understanding. We kindly ask you to fill out this form WITHIN 24 hours and prior to each appointment. If the patient is under 18 years old, this form should be filled out and signed by the parent/guardian.
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Patient's last name *
Patient's first name *
Parent/Guardian name if patient is a minor
In the last 14 days, has the patient, anyone accompanying the patient, or any family member had any of the following symptoms ? *
Yes
No
Fever (defined as above 100° F degrees)
Chills
Cough or sore throat
Unexplained muscle pain or headache
Diarrhea
Nasuea or vomiting
Shortness of breath and/or trouble breathing
Persistent pain, pressure or tightness in the chest
Recent loss of taste or smell
In the past 14 days, has the patient, anyone accompanying the patient, or any family member *
Yes
No
Had close contact with anyone diagnosed of COVID-19
Been diagnosed of COVID-19
If yes to the last question, please provide the date of close contact or date of diagnosis
MM
/
DD
/
YYYY
Orthodontic Treatment Consent

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, just as you might be at your gym, grocery store, or favorite restaurant. “Social Distancing” nationwide has reduced the transmission of the Coronavirus. Although we have taken measures to provide social distancing in our practice, due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, orthodontist, orthodontic staff and sometimes other patients at all times.
Although exposure is unlikely, do you accept the risk and consent to treatment? *
If the answer to any of these questions changes before the appointment, I agree to notify Florian Orthodontics as soon as possible. If the answer to any of these questions is yes, I will be asked to reschedule today’s orthodontic appointment to a later date *
Patient signature or Parent/Guardian signature if patient is a minor: *
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