Health Questionnaire | Wired Orthodontics

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?

Yes
No

If yes, when?

Do you, your child, or others accompanying you to today's appointment or other recent acquaintances:

Have a cough?

Yes
No

Have you/they come into close contact (within 6 feet) with someone who has a laboratory confirmed COVID-19 diagnosis in the past 14 days?

Yes
No

Do you/they have a fever (defined as greater than 100.4 degrees)?

Yes
No

Have any other Flu-Like symptoms such as gastrointestinal upset, headache, or fatigue?

Yes
No

Have a recent loss of taste or smell?

Yes
No

Do you/they have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?

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. (Please Type "I understand")

Any other changes to your/their medical history in the last 12 months?

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, just as you might be at your gym, grocery store, or favorite restaurant. "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?

Yes
No

I CERTIFY THAT THE INFORMATION I PROVIDED TODAY IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. MY DIGITAL SIGNATURE (BY TYPING NAME) CONFIRMS I HAVE READ AND UNDERSTAND ALL INFORMATION CONTAINED IN THIS DOCUMENT PROVIDED TO ME BY DR. YOO. (Please type your name below):

Patient First Name:*

MI

Patient Last Name:*

* Patient/Parent/Guardian Signature (Please Type):*

Date:

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Supplemental Health Questionnaire

SUPPLEMENTAL INFORMED CONSENT

Orthodontic Treatment in the Era of COVID-19