Thalman Orthodontics Welcome

**REQUIRED COVID-19 CONSENT FORM & HEALTH QUESTIONNAIRE**
Prior to every appointment, we require a new Health Questionnaire.

AAOIC 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.

* Indicates required field

Although exposure is unlikely, do you accept the risk and consent to treatment? *

Yes No

Patient Name *

First

Last

Patient/Parent's Signature *

First

Last

Date: *

Submit

AAOIC 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:

* Indicates required field

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? *

Yes No

If yes, When? *

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

A fever (defined as above 99.6 degrees) A cough? Shortness of breath and/or trouble breathing? Persistent pain, pressure, or tightness in the chest? None of the above

I understand that if the answer to any of these questions is yes, I will be asked to reschedule today’s orthodontic appointment.

Patient Name *

First

Last

Patient/Parent's E-Signature *

First

Last

Submit

Your team for your orthodontic needs!

AAOIC SUPPLEMENTAL INFORMED CONSENT
Orthodontic Treatment in the Era of COVID-19

AAOIC SUPPLEMENTAL HEALTH QUESTIONNAIRE

How to get
started

New
Forms

More
Information

Find and
Contact Us

﻿﻿Your team for your orthodontic needs! ﻿﻿﻿

AAOIC SUPPLEMENTAL INFORMED CONSENTOrthodontic Treatment in the Era of COVID-19

AAOIC SUPPLEMENTAL HEALTH QUESTIONNAIRE

How to getstarted

NewForms​

MoreInformation

Find andContact Us

Your team for your orthodontic needs!

AAOIC SUPPLEMENTAL INFORMED CONSENT
Orthodontic Treatment in the Era of COVID-19

How to get
started

New
Forms

More
Information

Find and
Contact Us