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AAOIC Supplemental Informed Consent/Questionnaire

Communicable Diseases and Your Orthodontist

With community transmission of communicable diseases, you could be exposed anywhere to infectious diseases including but not limited to Covid-19 (also called Coronavirus). Our orthodontic office is following the State and Federal regulations and recommended universal personal protection and disinfection protocols to limit the transmission of communicable diseases. However, it is possible that these precautions will not always be successful in blocking the transmission of these diseases. Social distancing has reduced the transmission of Covid-19, however, it is not possible to provide orthodontic treatment with social distancing between the patient, orthodontist, orthodontic staff, and sometimes, other patients.

By Presenting yourself or your child for orthodontic treatment, you assume and accept the risk that you or your child may inadvertently be exposed to a communicable disease.

If you have been exposed to a communicable disease prior to your orthodontic appointment, you may spread the disease to the orthodontist, orthodontic staff, and to other patients/parents in the practice. Therefore, prior to each appointment, we require you to answer the following questions:

Which office?
Have you, your child, or others accompanying you to today's appointment been tested positive for or been diagnosed as having Covid-19
Do you, your child, or others accompanying you to today's appointment have:
A fever?
A cough?
Shortness of breath and/or trouble breathing?
Persistent pain, Pressure or Tightness in the chest

If any of you have any of these symptoms or have recently tested positive for or been diagnosed with Covid-19, you will be asked to reschedule your orthodontic appointment.

Do you acknowledge and accept the risk of exposure in our orthodontic office to a communicable disease, including but not limited to Covid-19, and consent to treatment?