COVID19 Supplemental Health Form


It is required that a form be filled out for each person entering our office. This form is for (full name):

Orthodontic Treatment in the Era of COVID-19


If you have been exposed to a communicable disease, you may spread the disease to the orthodontist, orthodontic staff, or other patients/parents in the practice. Therefore, prior to each appointment, we will be asking the following questions in order to reduce the chances of transmission:

Are you, your child, or others accompanying you to today's appointment in a high risk category: diabetes, cardiovascular disease, high blood pressure, lung disease, moderate to severe asthma, immunocompromised, cancer, or over 65 years of age?
Have you, your child, or others accompanying you to today’s appointment or anyone you have recently been in contact with tested positive for or been diagnosed with having COVID-19 or any other communicable disease?
If so, please indicate the date of your exposure or diagnosis.

Have you, your child, or others accompanying you to today’s appointment traveled outside of Canada by car, bus, train, or air within the past 14 days?

Do you, your child, or others accompanying you to today's appointment or anyone you have recently been in contact with have any of the following symptoms?
Fever (defined as above 38° C)?
Flu-like symptoms or sore throat?
Cough?
Runny nose or sneezing?
Shortness of breath and/or trouble breathing?
Persistent pain, pressure, or tightness in the chest?

COVID19 Supplemental Informed Consent

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 flu, you may be exposed to COVID-19, also known as "Coronavirus", at any time or in any place. Acquiring any infection while in our office is unlikely because we continue to follow provincial and federal regulations that require universal personal protection and disinfection protocols to limit transmission of all diseases in our office as we always have done.
"Social Distancing" nationwide has reduced the transmission of the Coronavirus. Although we have taken measures to provide social distancing in our practice waiting room, due to the nature of the services we provide, it is not possible to maintain social distancing between patients, orthodontist, and orthodontic staff in the clinical area. Thus, as an additional measure, anyone visiting a dental office is asked to come in wearing a mask or similar face covering.
I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic.
Patient First Name:
MI:
Last Name:
Parent/Guardian First Name:
MI:
Last Name:
Relationship to Patient:
Patient/Parent/Guardian Signature:
Date: