PATIENT INFORMED CONSENT - Vancouver Orthodontist Dr. Loo

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Orthodontic Treatment in the Era of Communicable Diseases (ie: Covid & Influenza)

Patient Nameyour full name

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 provincial 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, use of personal barriers, and isolated treatment areas, there is still a chance that you could be exposed to an illness in our office. “Physical Distancing” has reduced the transmission of the Coronavirus. Although we have taken measures to provide physical distancing in our practice, due to the nature of the procedures we provide, it is not possible to maintain physical distancing between the patient, orthodontist, orthodontic staff and sometimes other patients at all times.

Please read and acknowledge by your initial in all areas indicated. If you have any questions please do not hesitate to contact our office.

1. I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. I understand the novel coronavirus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. For this reason, it is recommended to stay home and avoid close contact with other people when at all possible.Please Initial

2. I understand that it is possible that dental cleanings can create water and/or blood spray, which may be one way that the novel coronavirus can spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which may transmit the novel coronavirus.Please Initial

3. I understand the federal and provincial governments have asked individuals to maintain physical distancing of a least 2 metres (6 feet) and I recognize it is not possible to maintain this distance while receiving orthodontic treatment.Please Initial

4. I confirm that I do not have any two or more of the following symptoms of COVID-19: fever, new or worsening cough, sore throat, runny nose or headache, and that this is not currently a period where I am required to self-isolate for 5 days.Please Initial

Although exposure is unlikely, do you accept the risk and knowingly and willingly consent to have orthodontic treatment for yourself or your child completed during the COVID-19 pandemic?please choose one

YesNo

Patient Signature: By initialing each box above and typing out your name below you acknowledge that you understand the risks affiliated with visiting the dentist during a pandemic and acknowledge that you will adhere to all of our office rules and that you are not experiencing any symptoms and are not required to be quarantined.

Signature of Patient (if over 18), Parent/Guardian

Date

Adapted from BC Dental Association COVID-19 Pandemic Guidelines (as of May 22, 2020)

Dr. Angelina Y.C. Loo, Inc./ Dr. Edwin H.K. Yen

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