Frost Orthodontics

COVID-19 Release Waiver


I,  ,  acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.  I acknowledge that this is a one-time agreement that applies to future appointments, as well as present.
I further acknowledge that Frost Orthodontics has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.
I further acknowledge that Frost Orthodontics can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, staff, and other patients and their families.
I voluntarily seek services provided by Frost Orthodontics and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending all of my appointments for the duration of treatment..

 

I attest that at the time of each appointment:

*I am not experiencing any symptoms of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
* I have not traveled internationally within the last 14 days.
* I have not traveled to a highly impacted area within the United States of America in the last 14 days.
* I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.
* I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities.
* I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.

 

I hereby release and agree to hold Frost Orthodontics harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the practice, or that may otherwise arise in any way in connection with any services received from Frost Orthodontics. I understand that this release discharges Frost Orthodontics from any liability or claim that I, my heirs, or any personal representatives may have against Frost Orthodontics with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Frost Orthodontics. This liability waiver and release extends to the practice together with all owners, partners, and employees.

 

 

Patient (Over 18) or Parent/Guardian (under 18), please sign below.

Leave this empty:

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Signature Certificate
Document name: COVID-19 Release Waiver
lock iconUnique Document ID: 9e0c880f8cb9d86b732dacf8d747e714b221e7a9
Timestamp Audit
December 14, 2020 1:27 pm MSTCOVID-19 Release Waiver Uploaded by Stuart Frost - smiles@frostortho.com IP 72.215.202.99