AAO Wellness Form

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AAO Wellness Screening

"*" indicates required fields

Pick Your Office*

Have you, your child, others accompanying you to today’s appointment, or anyone in your household tested positive for Covid-19, been diagnosed as having Covid-19, or been in close contact with someone who has tested positive for Covid-19?*

Yes

If so, when?*

MM slash DD slash YYYY

Do you, your child, others accompanying you to today’s appointment, or anyone in your household have:

A fever?*

Yes

A cough?*

Yes

Shortness of breath and/or trouble breathing?*

Yes

Persistent pain, pressure or tightness in the chest?*

Yes

If any of you have any of these symptoms or have recently tested positive for or been diagnosed with Covid-19, you will be asked to reschedule your orthodontic appointment.

Do you acknowledge and accept the risk of exposure in our orthodontic office to a communicable disease, included but not limited to Covid-19, and consent to treatment?*

Yes

Date

MM slash DD slash YYYY

Email*

Patient's Name*

Name

Patient/Guardian's Signature*

First

By typing my name in the Signature field, I am providing my e-signature, which will have the same legal effect as a handwritten signature. I am also certifying the above information to be true and accurate to the best of my knowledge.

CAPTCHA

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