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Covid-19 Questionnaire
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Home
About us
Services
Patient Center
Financing
Contact Us
Covid 19 Update
Covid 19-Consent Form
Covid-19 Questionnaire
Coronavirus (COVID-19) Questionnaire
If you have been exposed to coronavirus (COVID-19), you may spread the virus to your Orthodontist, her team, or other patients/parents/visitors to the Practice. Therefore, prior to each appointment, we will be asking you to confirm answers to the following questions to reduce the chances of transmission of COVID-19 in our Practice.
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.
Patient Details
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Indicates required field
Patient Name
*
First
Last
First name Last name
Next Appointment Date:
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Please fill in the next appointment date
Health Questions
Have you, your child, members of your family, others accompanying you to your next appointment or other recent acquaintances(anyone you have recently in contact with) tested positive for, or been diagnosed as having Coronavirus (COVID 19)?
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Yes
No
Have you, your child, your family members or other persons accompanying you to your next appointment or anyone in contact with you recently had any of the following symptoms?
Fever (greater than 100.4F) or cough?
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Yes
No
Shortness/difficulty of breathing or sore throat?
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Yes
No
Headache, muscle/body aches, fatigue or gastrointestinal upset/diarrhea?
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Yes
No
Persistent pain, pressure, or tightness in your chest?
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Yes
No
New loss of taste or smell?
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Yes
No
Have you returned from travel overseas, interstate, a cruise ship or travelled outside the IL area in the last 14 days?
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Yes
No
If you answer Yes to any of the Health Questions below, you will be asked to reschedule your next orthodontic appointment to a later date.
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Informed consent for orthodontic treatment during the COVID-19 pandemic
I understand that COVID-19 has a long incubation period during which time carriers of the virus may show no symptoms and still be highly contagious. It may not be possible to determine whether someone has COVID-19 or not given current limits in virus testing. I understand that there is therefore a risk that a person attending Ahn Orthodontics on Lincolnshire, IL may be infected with COVID-19 and expose either me, my child or an accompanying person to COVID-19.
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Yes
No
In light of the known risks in relation to contracting COVID-19, I consent to me or my child (as relevant) receiving orthodontic treatment at Ahn Orthodontics on Lincolnshire, IL during the COVID-19 pandemic period.
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Yes
No
Patient/Parent/Guardian E-Signature
*
Please type in your full name
Today's Date
*
We thank you for your understanding in implementing these measures which are designed to preserve your health and safety, that of our other patients and our team, and limit the community transmission of COVID-19. If you have any questions in relation to this COVID-19 Questionnaire and the protocols in place in our office, please email
ahnorthodontics@gmail.com
.
We look forward to seeing you soon.
Submit
Thank you for your cooperation in helping us make a safer environment!
Home
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Covid 19 Update
Covid 19-Consent Form
Covid-19 Questionnaire
