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AAO Wellness Form
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AAO Wellness Screening
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Clarksville
Madison
Scottsburg
Louisville
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?
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Yes
No
If so, when?
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MM slash DD slash YYYY
Do you, your child, others accompanying you to today’s appointment, or anyone in your household have:
A fever?
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Yes
No
A cough?
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Yes
No
Shortness of breath and/or trouble breathing?
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Yes
No
Persistent pain, pressure or tightness in the chest?
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Yes
No
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?
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Yes
No
Date
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Email
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Patient's Name
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Name
Patient/Guardian's Signature
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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.
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