COVID19 Consent Form

Orthodontic Treatment in the Era of COVID-19

Please select the Practice you are attending:

PortlaoiseCarlowKilkenny

Thank you for your continued trust in Castle Orthodontics. 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 regulations, recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our offices and continue to do so.

Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be at the grocery store. Although we have taken measures to provide social distancing in our practice, due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, orthodontist, orthodontic staff and sometimes other patients at all times.

Although exposure is unlikely, do you accept the risk and consent to treatment?

If you have been exposed to a communicable disease, you may spread the disease to the orthodontist, orthodontic staff, or other patients/parents in the practice. Therefore, prior to each appointment, we will be asking the following questions to reduce the chances of transmission:

Have you, your child, or others accompanying you to today’s appointment or other recent acquaintances tested positive for or been diagnosed as having COVID-19 or any other communicable disease?YesNo

If yes, when?

Have you, the patient, travelled outside the country in the previous 14 days?YesNo

Do you, your child, or others accompanying you to today’s appointment or other recent acquaintances have:

A Fever (defined as 38oC or above)YesNo

A CoughYesNo

Shortness of Breath and/or Trouble Breathing?YesNo

Persistent Pain, Pressure, or Tightness in the Chest?YesNo

I understand that if the answer to any of these questions is yes, I will be asked to reschedule today’s orthodontic appointment.

Patient/Parent’s Name

Today's Date: