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Orthodontic Services | Queens | Brooklyn | Long Island NY
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Covid-19 Waiver
Albert Aranbaev
2020-06-12T01:52:13+00:00
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
If yes provide approximate dates of illness
MM slash DD slash YYYY
Through
MM slash DD slash YYYY
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
Parent/Guardian First Name:
MI:
Last Name:
Relationship to Patient?
Signature
Date
MM slash DD slash YYYY
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