1) I willingly and knowingly consent to dental treatment by West End Orthodontics, including any designated associates and team members during the COVID-19 pandemic.
2) I understand that West End Orthodontics is observing the guidelines from the Centers for Disease Control and Prevention for its recommended treatment and infection control protocols.
3) I am not aware of any risk whereby I might be infected or a possible carrier of COVID-19. I confirm that I have not tested postiive for COVID-19 in the last 10 days, nor have I had any of the following symptoms of COVID-19 for the past 10 days:
A. Fever of 100.5 degrees Fahrenheit (or 37 degrees Celsius) or higher
B. Shortness of breath
C. Dry cough
D. Runny nose
E. Sore throat
F. Dimished sense of taste and/or smell
4. I confirm that I am not aware of being in close contact (6 feet or fewer) in the last 14 days for 15 minutes or more with anyone who tested positive of being infected with COVID-19, nor have I knowingly been in contact with anyone who has the symptoms stated above in the last 14 days.
5. I confirm that I have not traveled outside the United States in the past 14 days. I can confirm that I have not traveled domestically via commercial airline, train, bus or any other public transport within the past 14 days.
6. I understand that COVID-19 has a substantial incubation period in which carriers of the virus may not demonstrate symptoms while still being highly contagious. I understand that it is not possible to determine which individuals are infected and which are not, given the current limitations and availability of COVID-19 testing. I understand that several dental procedures create water spray, which is one method in which the virus can be spread. I understand that the ultra-fine, mist-like nature of the water spray can linger in the air for hours, which can transmit COVID-19.
7. I understand that, due to the frequency of the visits from other dental patients, the characteristics of the virus, and the characteristics of dental procedures, that I may have an elevated risk of contracting COVID-19, simply by being present in a dental office, even though the recommended guidelines from the Centers for Disease Control and Prevention and the local health department are being observed.
8. Informed Consent: I acknowledge that I have been given the opportunity to ask any questions regarding the risks of contracting COVID-19 while visiting the dental office and while receiving dental procedures. I reaffirm that I am not a known carrier of COVID-19, nor have I been exposed to or infected with COVID- 19, to the best of my knowledge. I do voluntarily assume any and all reasonable medical / dental risks, including the substantial and significant risk of serious harm, if any, which may be associated with any phase of my treatment, as a result of the COVID-19 pandemic. I acknowledge that the nature and purpose of the prescribed dental procedures have been explained to me, as needed, and I have also been given the opportunity to ask questions.
The information given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform the office of any changes.