Wellness Screening & Treatment Consent

In the last 14 days, has the patient (or any member of the household) had any of the following?

Has the patient, a family member, or any known close contact had any of the following occur?

Diagnosis of COVID-19 infection, or any other communicable disease

Waiting on results of test for COVID-19 infection

Symptomatic but unable to get tested for COVID-19

If the patient, family member, or close contact has been diagnosed with COVID-19 infection, when did that occur?

If the answer to any of these questions changes before or after the appointment, I agree to notify Dr. Rosario's office as soon as possible. Also, if the answer is yes to any of the previous questions, I understand I will be asked to reschedule the appointment.

Treatment Consent: Please be assured that our office has always met or exceeded the requirements set forth for sterilization and infection control from the ADA and Health Authorities, and will continue to do so. However, it is possible to contract COVID-19 infection (or any other communicable disease) in any public space. Our practice will provide for socially distant appointment scheduling, and also has added a number of new technologies and techniques to the practice to enhance our level of safety. However, due to the nature of orthodontic treatment, a 1.5 metres distance is not possible between the orthodontic patient and clinical staff/doctor. Re-entering public life comes with some risks that we all must weigh, but we also want you to feel confident that our office is taking every step to keep our patients and staff safe during this difficult time. By ticking "yes" below, indicates that the risks involved are accepted, and that consent is given for treatment to be provided by Dr Rosario Rodriguez and staff.

Your Name

Patient Name (if different)