Home » COVID-19 Patient FormsCOVID-19 Patient FormsPlease fill out the following form prior to your scheduled appointment. Supplemental Health Questionnaire and Supplemental Informed Consent Form Orthodontic Treatment in the Era of COVID-19 If you have been exposed to a communicable disease, you may spread the disease to the orthodontist, orthodontic staff, or other patients/parents in the practice. Therefore, prior to each appointment, we will be asking the following questions to reduce the chances of transmission: Do you, your child, others accompanying you to today’s appointment or anyone you have recently been in contact with have any of the following symptoms?Fever (defined as above 100.4 degrees)? *YesNoCough? *YesNoShortness of breath and/or trouble breathing? *YesNoPersistent pain, pressure, or tightness in the chest? *YesNoFlu like symptoms (chills, body aches, fatigue, joint pain, etc.)? *YesNoChange in taste or smell? *YesNoHave you, your child, others accompanying you to today’s appointment or anyone you have recently been in contact with tested positive for or been diagnosed as having COVID-19 or any other communicable disease? *YesNoIf yes provide approximate dates of illness Print Patient Name *Legal Guardian/Parent Name Date *Cell Number of Patient/Parent *Make, Model & Color of Vehicle *Location of your scheduled appointment *First Colonial Road OfficeEastern Shore OfficeGeneral Booth Blvd OfficeKempsville Road OfficePleasure House Road Office 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? YesNoPatient/Parent's Signature *Date * VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>:
