INFORMED CONSENT

INFORMED CONSENT
PATIENT NAME*
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 know as “Coronavirus” at any time or place. Be assured the 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 continued 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 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?*

YesNo
Covid-19 Health Screening Questionnaire
Do you, your child or anyone you have recently been in contact with have any of the following symptoms?
Fever*
Cough*
Shortness of breath or difficulty breathing.*
Persistent pain, pressure, or tightness in the chest*
Recent loss of taste or smell*
Have you and/or your child recently been in contact with anyone who tested positive for or has
been diagnosed as having COVID 19?*
If yes, when was the last contact with the patient?
Have you traveled outside Illinois within the last 14 days?*
If yes, where did you go and when did you return?
PATIENTS WITH A FEVER OF 100.4 DEGREES OR HIGHER AND THOSE WITH HIGH RISK CONTACTS OR TRAVEL WILL NOT BE ADMITTED FOR APPOINTMETNS AT THIS TIME
Patient/Parent Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

INFORMED CONSENT

Orthodontic Treatment in the Era of COVID-19

Covid-19 Health Screening Questionnaire