COVID Questionnaire | Dr. Andrew Willoughby

Todays date (MM/DD/YYYY) *

Items marked with asterisk (*) must be completed.

Patient's Name *

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? *

If yes, when?

Do you, your child, or others accompanying you to today’s appointment or other recent acquaintances have any of the following symptoms: Fever (defined as above 99.6 degrees)? *

Cough? *

Shortness of breath and/or trouble breathing? *

Persistent pain, pressure, or tightness in the chest? *

Other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue? *

Recent loss of taste or smell? *

Have you/they traveled in the past 14 days to any regions affected by COVID-19? *

Any heart disease, kidney disease, diabetes, or autoimmune disorders? *

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

First and Last Name of person who completed this form *

Please type your name as acknowledgment and digital signature of Form 1 *

Single Line Text

Patient name *

New patients complete Section 1 and 2. Existing Patients complete Section 2 only.

Section 1

I, the legally authorized surrogate decision maker, do hereby request treatment at Aran Orthodontics for the above listed patient. I authorize the attending office, staff of the procedures, including the administration of anesthetics, and the use of radiographs (X-rays) as may be recommended for my treatment. I also authorize the taking of images (including for example photographs, radiographs and films) and the creation of any other records (electronic and/or hard-copy) for the purpose of treatment, teaching, presentations, publications, research, or marketing. I understand that the records will be anonymized in order to protect my identity. Further, if applicable, I authorize the Aran Orthodontics to release the required records to my dental insurance provider(s) in order to submit a pre-determination for treatment and to receive payment from the insurance provider for services rendered.

Please type your name as acknowledgment and digital signature of Section 1.

Section 2

Supplemental Informed Consent for Orthodontic Treatment in the Era of Covid-19 Thank you for your 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 provincial 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 clinic, just as you might be at you’re your gym, grocery store or favorite restaurant. “Physical Distancing” has reduced the transmission of the Coronavirus. Although we have taken measures to provide distancing within our practice, due to the nature of the procedures we provide, it is not possible to maintain physical 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? *

Please type your name as acknowledgment and digital signature of Section 2 *

Date *

First Name *

Last Name *

(copy)

Street *

City *

State/Province *

Zip/Postal Code *

Country *

Home Phone

Cell/Mobile *

Email Address *

Birth date (MM-DD-YYYY)

Gender

If patient is a minor, give parent's or guardian's name

Whom may we thank for referring you to our office?

Other family members seen by us

Name of your General Dentist

Approximate date of last visit (MM-DD-YYYY)

Responsible Party Information

Do not enter anything in the Responsible Party Information bar above.

Mother's Full Name

Home Phone

Cell/Mobile

Email Address

Residence (if different from above)

Do not enter anything in the Residence bar above.

Street

City

State/Province

Zip/Postal Code

Country

Father's Full name

Home Phone

Cell/Mobile

Email address

Residence (if different from above)

Do not enter anything in the Residence bar above.

Street

City

State/Province

Zip/Postal Code

Country

Are there any other Responsible Parties? Please list name, phone number and email address

Dental Insurance Information Section

Do not enter anything in the Dental Insurance bar.

Insured's Name

Insured's Birth date (MM-DD-YYYY)

Insurance Company

Group/Policy/Plan Number

ID/Certificate Number

Do you have dual coverage?

Medical History Section

Do not enter anything in the medical history bar.

Physician

Please check any of the following which apply to you, and add any relevant comments.

Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.

Are you taking any medication?

Comment

Are you allergic to any medication?

Comment

Do you have a history of any major illness?

Comment

Have you had any major operations?

Comment

Are there any medical conditions we have not discussed that you feel we should be aware of?

By clicking the "Submit Form" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.