Richardson Orthodontics: Wellness and Consent Form

For your protection, you will notice a few physical changes within the office, and we have also implemented new safety guidelines. Our elevated infection control standards meet or exceed what is being recommended by the NS Provincial Dental Board to keep everyone safe. However, before we can see you, please complete the following Covid-19 health questionnaire and consent to treatment form.

Please do not complete this form until after 6 pm the night before your scheduled appointment.

In the last two weeks have you had:*

	YES	NO
1. Fever greater than 38°C?
2. Flu-like symptoms including chills, sweats, or muscle/ body aches?
3. Cough or runny nose?
4. Headache or light-headedness?
5. Sore throat or difficulty swallowing?
6. Shortness of breath or difficulty breathing?
7. Decreased or lost sense of taste or smell?
8. Been to one of the exposure sites listed on the NS Health Authority website as listed on https://NShealth.ca/coronavirus-exposure
9. Been in close personal contact with anyone who has had any of these symptoms?
10. Been in close personal contact with anyone who tested positive for Covid-19?
11. Been tested for Covid-19 or have a positive test result for Covid-19?
12. Have you travelled outside of Nova Scotia in the last 14 days?

In the event that a patient answers yes to any question, or is found to have a temperature greater than 38º on the day of their appointment, the appointment will be rescheduled to avoid any risk of infection to other patients and our staff.

It is possible to contract the Covid-19 virus (or any other communicable disease) in public places. The Nova Scotia Chief Medical Officer of Health has asked individuals to maintain physical distancing of 2 meters (6 feet) and it is not possible to maintain this distance and receive Orthodontic treatment.

Some Orthodontic procedures create a fine mist (aerosol) which can linger in the air for minutes or hours, and it is possible that aerosols may transmit Covid-19. We have implemented new protocols and procedures to help reduce the amount of aerosol production in our clinic, though we cannot eliminate them completely.

Due to the frequency of visits of other Orthodontic patients, the virulent nature of Covid-19, and aerosols generated by some procedures, you may have an elevated risk of contracting Covid-19 by being in our office. Furthermore, patients who have moderate to severe Asthma, or other medical conditions that cause immunosuppression, can have an increased risk of serious illness should they contract the Covid-19 virus.

We ask that you please inform our office if the patient develops symptoms or is diagnosed with COVID-19 within the 14 days following their orthodontic appointment.

Name*

First NameLast Name

Today's Date*

Date

Must be signed! Signature by Guardian if patient under 18 years of age*