Frost Orthodontics

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, do you accept the risk and consent to treatment?


AAOIC SUPPLEMENTAL HEALTH QUESTIONNAIRE


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 to reduce the chances of transmission:


Have you, your child, or others accompanying you to today’s appointment or other recent acquaintances tested positive for or been diagnosed as having COVID-19 or any other communicable disease?

Do you, your child, or others accompanying you to today’s appointment or other recent

acquaintances have:

A Fever (defined as above 99.6 degrees)?

A Cough?

Shortness of Breath and/or Trouble Breathing?

Persistent Pain, Pressure, or Tightness in the Chest?

I understand that if the answer to any of these questions is yes, I will be asked to reschedule today’s orthodontic appointment.

By signing this document, I also commit to rescheduling any future appointment if I have any of the symptoms listed above within 72 hours of my scheduled appointment.

Patient Name (If being signed by parent/guardian):   

 

 

Leave this empty:

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Signature Certificate
Document name: AAOIC SUPPLEMENTAL INFORMED CONSENT
lock iconUnique Document ID: 2ccdc068c8fa90a5e424cb432dc28091b78a3252
Timestamp Audit
April 29, 2020 2:38 pm MSTAAOIC SUPPLEMENTAL INFORMED CONSENT Uploaded by Stuart Frost - smiles@frostortho.com IP 72.215.202.99
April 29, 2020 3:55 pm MSTFrost Ortho - smiles@frostortho.com added by Stuart Frost - smiles@frostortho.com as a CC'd Recipient Ip: 184.190.147.173
April 30, 2020 9:15 am MSTFrost Ortho - smiles@frostortho.com added by Stuart Frost - smiles@frostortho.com as a CC'd Recipient Ip: 184.190.147.173
April 30, 2020 11:01 am MSTFrost Ortho - smiles@frostortho.com added by Stuart Frost - smiles@frostortho.com as a CC'd Recipient Ip: 72.215.202.99
April 30, 2020 11:35 am MSTFrost Ortho - smiles@frostortho.com added by Stuart Frost - smiles@frostortho.com as a CC'd Recipient Ip: 72.215.202.99
April 30, 2020 11:36 am MSTFrost Ortho - smiles@frostortho.com added by Stuart Frost - smiles@frostortho.com as a CC'd Recipient Ip: 72.215.202.99
April 30, 2020 11:37 am MSTFrost Ortho - smiles@frostortho.com added by Stuart Frost - smiles@frostortho.com as a CC'd Recipient Ip: 72.215.202.99
April 30, 2020 11:38 am MSTFrost Ortho - smiles@frostortho.com added by Stuart Frost - smiles@frostortho.com as a CC'd Recipient Ip: 72.215.202.99
July 29, 2020 8:40 am MSTFrost Ortho - smiles@frostortho.com added by Stuart Frost - smiles@frostortho.com as a CC'd Recipient Ip: 72.215.202.99