Health Questionnaire and Informed Consent
Orthodontic Treatment in the Era of COVID-19
We would like to thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or flu, you may have been exposed to COVID-19, at this time or in any place. Infection control has and will always be a top priority for our practice. We would like to assure you 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 will continue to do so in the Era of COVID-19.
Even with our careful attention to sterilization, disinfections 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, favorite restaurant or grocery store. For the unforeseeable future, we will be taking measures to provide social distancing in our practice. However, 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 highly unlikely, do you accept the risk and consent to being seen in our office for you or your child’s appointment?
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:
Do you, your child, or others accompanying you to today’s appointment or anyone you have recently been in contact with have any of the following symptoms?
Do you, your child, or others accompanying you to today’s appointment or anyone you have recently been in contact with tested positive for or been diagnosed as having COVID-19 or any other communicable disease?
If yes, provide approximate dates of illness:
I understand that if the answer to any of these symptom-related questions is yes, I may be asked to reschedule today’s orthodontic appointment to a later date.