Oltjen Orthodontics – Check-In Parent or legal guardian’s name* First Last What is the patient's name?* First Last Do You Need Parental Consent?*I'm Over 18I'm Under 18I'm A ParentHave you, or anyone with you, traveled overseas in the last 14 days?*YesNoHave you, or anyone with you, traveled within the USA by air, bus, or train in the last 14 days?*YesNoHave you, or anyone with you, been tested for COVID-19 and are awaiting the results?*YesNoHave you, the patient, or any of your recent acquaintances tested positive for COVID-19 or any other diseases in the last 14 days?*YesNoHave you come into contact with anyone experiencing symptoms of COVID-19 in the last 14 days?*YesNoHave you, the patient, or anyone with you, experienced a persistent cough in the last 14 days?*YesNoHave you, the patient, or anyone with you, experienced shortness of breath in the last 14 days?*YesNoHave you, the patient, or anyone with you, experienced chest pressure in the last 14 days?*YesNoHave you, the patient, or anyone with you, had a fever in the last 14 days?*YesNoAre you 65 years or older?*YesNoDo you have any chronic immune or systemic conditions?*YesNoConsent to Treatment*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. Although exposure is unlikely, do you accept the risk and consent to treatment?Parent/Guardian Signature*By signing the document above, and filling out this form, I confirm that I understand the questions presented to me and that I’ve answered all these questions honestly. I also understand that these answers may result in being asked to reschedule today’s appointment. I confirm that I am not a minor, am the legal guardian of this patient, or am an adult patient filling this out for themselves. If you answered “YES” to any of these questions a deeper discussion with Dr. Oltjen will be necessary before proceeding with treatment.You may be required to reschedule your appointment 14 plus days later.PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.