Hallmark Orthodontics COVID-19 Patient Consent

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I knowingly and willingly consent to have orthodontic treatment completed during the COVID-19 pandemic and thereafter. Hallmark Orthodontics is taking every necessary precaution to limit the spread of the disease and is making your health our number one priority. We are following the State and Federal regulations as well as universal personal protection and disinfection protocols to limit transmission of communicable diseases.

I have reviewed the following: *

I understand that the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.

I understand that due to the frequency of visits of other orthodontic patients, the characteristics of the virus, and the characteristics of certain orthodontic procedures, that it is possible I have an increased risk of being exposed to the virus in an orthodontic office.

I understand that current guidelines by the CDC include 6 feet distance between individuals and that this is not possible with orthodontic treatment.

I have been made aware of the CDC and IDA guidelines for orthodontic offices and am confident that Hallmark Orthodontics is following the necessary precautions and guidelines.

Other:

Required

I confirm that neither my child or myself are presenting with the following symptoms now or within 14 days: *

A confirmed diagnosis of COVID-19 for myself, my child, or anyone I have been knowingly exposed to

Fever

Shortness of Breath and/or Trouble Breathing

Dry Cough

Runny Nose

Sore Throat

Persistent Pain, Pressure, or Tightness in the Chest

Other:

Required

I confirm that neither my child or myself have traveled outside the United States or domestically by commercial airline, bus, or train within the past 14 days:

Yes, I can confirm this is true

No, I can not confirm this is true

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Patient Name *

Legal Guardian E-Sign Name (if Minor) *

Date *

YYYY

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