Refine Orthodontics Patient Acknowledgement Form: COVID-19 Pandemic Emergency Dental Risk
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Patients Name:
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First Name
Last Name
I understand there is currently a health pandemic associated with COVID-19 and the novel coronavirus.
I understand public health authorities have recommended maintaining social distancing of at least 2 meters (6 feet) and it is not possible to maintain this distance while receiving orthodontic treatment.
I understand that oral surgery/dental procedures can create water and/or blood spray, and that there may be an elevated risk of contracting and spreading the novel coronavirus in a dental office
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I confirm that I do NOT have any TWO OR MORE of the following symptoms of COVID-19: fever, new or worsening cough, sore throat, runny nose or headache and that this is not currently a period where I am required to self-isolate for 14 days.
I confirm that I have not tested positive for COVID-19 and that I am not currently waiting for the results of a test for COVID-19.
I hereby consent to have dental treatment completed during the COVID-19 pandemic.
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Name of Parent/Guardian Signing (if applicable):
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