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AAOIC SUPPLEMENTAL INFORMED CONSENT/QUESTIONNAIRE
Communicable Diseases and Your Orthodontist

With community transmission of communicable diseases, you could be exposed anywhere to infectious diseases, including, but not limited to COVID-19 (also called Coronavirus). Our orthodontic office is following the State and Federal regulations and recommended universal protection and disinfection protocols to limit transmission of communicable diseases. However, it is possible these precautions will not always be successful in blocking the transmission of these diseases. Social distancing nationwide has reduced the transmission of COVID-19, however, it is not possible to provide orthodontic treatment with social distancing between the patient, orthodontist, orthodontic staff and sometimes other patients.

By presenting yourself and your child for orthodontic treatment, you assume and accept the risk that you or your child may inadvertently be exposed to a communicable disease.

If you have been exposed to a communicable disease prior to your orthodontic appointment, you may spread the disease to the orthodontist, orthodontic staff and to other patients/parents in the practice. Therefore, prior to each appointment, we may perform a temperature screening upon entering the office. If a temperature higher than 100.4 is detected, we will reschedule your appointment.

Patient Signature (Parent/Guardian Signature if under 18 years)