stapletonortho

Patient Name*

First Last

Date Of Birth*

MM

DD

YYYY

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?*

YES
NO

Are you/they having shortness of breath or other difficulties breathing?*

YES
NO

Do you/they have a cough?*

YES
NO

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?*

YES
NO

Have you/they experienced recent loss of taste or smell?*

YES
NO

Are you/they in contact with any confirmed COVID-19 positive patients?*

YES
NO

Is your/their age over 60?*

YES
NO

Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*

YES
NO

Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)*

YES
NO

Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment. Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

AAOIC 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 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 transmission of all diseases in our office and continue 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, I accept the risk and consent to treatment.

Signature of Patient, Parent or Legal Guardian*

Parent or Legal Guardian Name:

Date:

Phone

This field is for validation purposes and should be left unchanged.

Stapleton Orthodontics