Supplemental Informed Consent
Thank you for your continued trust in our practice. As with the transmission of anycommunicable disease like a cold or the flu, you may be exposed to COVID-19, alsoknown as “Coronavirus,” at any time or in any place. Be assured that we have alwaysfollowed state and federal regulations and recommended universal personal protectionand 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 youmight be at your gym, grocery store, or favorite restaurant. “Social Distancing”nationwide has reduced the transmission of the Coronavirus. Although we have takenmeasures to provide social distancing in our practice, due to the nature of theprocedures we provide, it is not possible to maintain social distancing between thepatient, orthodontist, orthodontic staff and sometimes other patients at all times.
Although exposure is unlikely, do you accept the risk and consent to treatment?*
Yes No
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:
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?*
Do you, your child, or others accompanying you to today’s appointmentor 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 apply
I understand that if the answer to any of these questions is yes, I will be asked to reschedule today’s orthodontic appointment.*
Agree
Your Name
First Name Last Name
Patient's Name
First Name Last Name
Phone Number
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Should be Empty:

Supplemental Informed Consent

Supplemental Health Questionnaire