AAO SUPPLEMENTAL HEALTH QUESTIONNAIRE

AAO 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:
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?*
YesNo

When?*
MonthDayYear
**We will need to reschedule if you, your child, or other household members have tested positive for COVID-19 within six weeks of this appointment.

Do you, your child, or others accompanying you to today’s appointment have any of the following?
A fever (defined as above 100.4 degrees)*
YesNo
A cough?*
YesNo
Shortness of breath and/or trouble breathing?*
YesNo
Recent loss or reduction in your sense of smell?*
YesNo
Persistent pain, pressure. or tightness in the chest?*
YesNo
Have you been tested for COVID-19 and are awaiting results?*
YesNo
Have you traveled outside the US by air or cruise ship in the past 14 days?*
YesNo
Have you traveled inside the US by air, bus or train in the past 14 days?*
YesNo
I understand that if the answer to any of these questions is yes, I will be asked to reschedule my orthodontic appointment.
I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system.
By signing this document, I acknowledge that the answers I have provided above are true and accurate.
Paient Name*
First NameLast Name
Patient/Parent's Signature*
Clear
Date*
MonthDayYear
SUPPLEMENTAL INFORMED CONSENT
Orthodontic Treatment in the Era of COVID-19
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. “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?*
YesNo
Patient Name*
First NameLast Name
Patient/Parent's Signature*
Clear
Date*
MonthDayYear
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AAO SUPPLEMENTAL HEALTH QUESTIONNAIRE

SUPPLEMENTAL INFORMED CONSENT