COVID-19 Consent Form | Summers Ortho

knowingly and willingly consent to have orthodontic treatment during the COVID-19 pandemic.

I understand 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 who has it and who does not, given the current limits in virus testing.

Not many orthodontic procedures create aerosol spray, but, the ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the COVID-19 virus. We are limitng those types of procedures to protect our team and parents.

I understand that any type of travel significantly increases my risk of contracting and transmitting COVID-19 virus. I verify that I have not traveled outside of South Carolina in the past 14 days.

(Initial)

The CDC recommends social distancing of at least 6 feet for a period of 14 days to anyone who has traveled/ shows symptoms, and this is not possible with orthodontics.

(Initial)

Patient’s Name:

Signature

Date:

Relation to Patient

COVID-19 Pandemic Orthodontic Treatment Consent Form