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COVID-19 SCREENING & CONSENT FORM

If you have been exposed to a communicable disease, you may spread the disease to the dentists, orthodontists, members of their dental team, 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 appointment or other recent acquaintances have:  

A Fever (defined as above 99.6 degrees)
A Cough?
Stomach or other Gastrointenstinal issues?
Shortness of Breath and/or Trouble Breathing
Persistent Pain, Pressure, or Tightness in the Chest?

By checking this box I certify that I understand that if the answer to any of these questions is yes, I will be asked to reschedule today’s dental or orthodontic appointment.  

Dental and Orthodontic Treatment in the Era of COVID-19

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 the transmission of all diseases in our office and continue to do so.

 

Despite our careful attention to enhanced sterilization, disinfection, 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?  

Thanks for submitting!

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