COVID-19 Pandemic Dental/Ortho Treatment Consent Form

By submitting the form below, you knowingly and willingly consent to have dental/ortho treatment completed during the COVID-19 pandemic.

You agree that you understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in virus testing. Dental/Orthodontic procedures create water spray which is how the disease is spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the COVID-19 virus.

Your Name (required)

Your Email (required)

By checking each box below, you agree to the following:

I understand that due to the frequency of visits of other dental/ortho patients, the characteristics of the virus, and the characteristics of dental/ortho procedures, that I have an elevated risk of contracting the virus simply by being in a dental office.

I understand that my current dental/ortho treatment plan may change to be in compliance with the current ADA, CDC and local governments guidance concerning treatment recommendations during COVID-19 pandemic.

I understand that a telemedicine visit will be available, upon request, up to 48 hours prior to my appointment to address any concerns I might have about treatment.

I understand that if I do not submit this form 48 hours prior to my appointment the appointment will be rescheduled to a later date.

I confirm that I/My Child am not presenting any of the following symptoms of COVID-19: Fever, Shortness of Breath, Dry Cough, Sore Throat, Chills, Headache, New Loss of Taste or Smell. You agree to contact our office immediately if you, your child, or family member becomes ill with any of the above symptoms with-in 14 days of today’s dental treatment.

I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. The CDC recommends social distancing of at least 6 feet for a period of 14 days to anyone who has, and this is not possible with dentistry or orthodontics.

I verify that I have not traveled outside the United States in the past 14 days to countries that have been affected by COVID-19.

I verify that I have not traveled domestically within the United States by commercial airline, bus, or train within the past 14 days.

Prior to COVID-19 our office, as a courtesy, has submitted pre-authorizations for
treatment to your insurance company. As guidelines are rapidly changing, we are
currently unable to provide this benefit.

I understand that I will be asked to set up a payment plan prior to my child’s dental appointment. Please note that dental treatment will be rescheduled until a payment is in place.

Full name / signature: (required)

By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement.