Arbitman Orthodontics Informed Consent and Health Questionnaire

AAOIC SUPPLEMENTAL HEALTH QUESTIONNAIRE

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:

Patient Name

Responsible Party

Have you, your child, or anyone in your family traveled outside of the state in the last 30 days?

Yes No

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?

Yes No

If yes, when? Date

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)

Yes No

• A Cough?

Yes No

• Shortness of Breath and/or Trouble Breathing?

Yes No

• Persistent Pain, Pressure, or Tightness in the Chest?

Yes No

I understand that if the answer to any of these questions is yes, I will be asked to reschedule today’s orthodontic appointment.

Patient/Parent’s Signature

Date