Covid-19 Waiver - Amazing Smiles Orthodontics

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° F degrees)?

Yes
No

Chills?

Yes
No

Cough?

Yes
No

Sore Throat?

Yes
No

Shortness of breath and/or trouble breathing?

Yes
No

Persistent pain, pressure or tightness in the chest?

Yes
No

New loss of taste or smell?

Yes
No

Have you or others accompanying you to today’s appointment traveled outside of our local area or outside of the US within the past 14 days?

Yes
No

Have 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?

Yes
No

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

I Understand

Patient's Name*

First Middle Last

Orthodontic Treatment in the Era of COVID-19

Free Virtual Consultation Request