City Orthodontics

COVID-19 Pandemic Dental Treatment Consent

Are you immunocompromised?(Required)
Do you have any of the following symptoms: fever and/or chills, cough or barking cough, shortness of breath, decrease or loss of taste or smell, muscle aches/joint pain, extreme tiredness, sore throat, runny or stuffy/congested nose, headache, nausea, vomiting and/or diarrhea, abdominal pain, pink eye(Required)
**Select NO if both of these apply: You do not have a fever and your symptoms have been improving for 24 hours (48 hrs if you have nausea, vomiting and/or diarrhea)
Have you been told (by a doctor, health care provider, public health unit, federal border agent, or other government authority) that you should currently be quarantining, isolating or staying at home?(Required)
In the last 10 days, have you tested positive for COVID-19 on a laboratory-based PCR test, rapid molecular test, rapid antigen test or other home-based self-testing kit?(Required)
I am a parent / legal guardian that may be required to enter the office to accompany the patient. I confirm that the answers to the above questions apply to me as well.(Required)
Do you understand that it is not possible to maintain physical distancing during dental treatment?(Required)
I understand that due to the frequency of visits, of other dental patients, the characteristics of the novel coronavirus, and the characteristics of dental procedures, it is possible to acquire COVID-19 simply by being in a dental office.(Required)
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