Date of Birth*
At our office, your safety is our top priority. We want to assure you that while many things have changed, one thing remains the same, our unwavering commitment to patient safety to ensure you are both, safe and comfortable.
Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge.
Therefore, we ask that you answer a number of “screening” questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.
Have you, your child, or members of your household tested positive for, or been diagnosed as having COVID-19?* YesNo
1) Do you have one or more of the following symptoms: (Check all that apply)* FeverShortness of breathRunny NoseSore ThroatDry CoughNone of the above
2) Within the last 14 days, have you come in contact with a person who has a confirmed COVID-19 diagnosis?* YesNo
3) I understand that the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine whether someone has the virus or not, given the current limits in virus testing. I understand that there is a risk that a person attending Innovative Orthodontic Centers and/or Innovative Pediatric Dentistry may be infected with COVID-19 and expose me or my child to the virus.* Agree
4) In light of the known risks in relation to contracting COVID-19, I knowingly and willingly consent to me or my child (as relevant) receiving dental and/or orthodontic treatment during the COVID-19 pandemic.* YesNo
5) AS A PARENT/GUARDIAN, I understand that it is highly recommended that ONLY the patient getting treatment comes INTO the office. However, If I wish to accompany my child into the office, I understand the following: 1) I must fill out the PARENT/GUARDIAN section below of this form. 2) I will be required to comply with all of the office's COVID-19 protocols. 3) Only I, the person filling and signing this form, can accompany my child into the office.
I agree and WILL NOT be accompanying my child into the office.I agree and WILL be accompanying my child into the office.N/A
PARENT/GUARDIAN, do you have one or more of the following symptoms: (Check all that apply)* FeverShortness of breathRunny NoseSore ThroatDry CoughNone of the above
PARENT/ GUARDIAN, within the last 14 days, have you come in contact with a person who has a confirmed COVID-19 diagnosis?* YesNo
55 South Main St, Suite 261 Naperville, IL 60540
[email protected] (630) 848-PEDO
Mon: 8am-7pm Tues: 8am-7pm Wed: 9am-5pm Thurs: 8am-7pm Fri: 8am-4pm Sat: 8am-1pm
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