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Home
About us
Services
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Covid 19 Update
Covid 19-Consent Form
Covid-19 Questionnaire
SUPPLEMENTAL INFORMED CONSENT
Orthodontic Treatment in the Era of COVID-19
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 state 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, 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 your gym, grocery store, or favorite restaurant. "Social Distancing" nationwide has reduced the transmission of the Coronavirus. 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 supplemental informed consent of orthodontic treatment at Ahn Orthodontics (Lincolnshire, IL) in the era of COVID-19 as written above?
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Yes
No
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Indicates required field
Patient Name
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First
Last
Last name First name
Guardian Name (if applicable)
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First
Last
Please give us the full name of the patient's guardian if the patient is 18 years or younger
Relation
*
Patient/Parent/Guardian E-Signature
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Please type in your full name
Date
*
Submit
Thank you for your cooperation in helping us make a safer environment!
Home
About us
Services
Patient Center
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Contact Us
Covid 19 Update
Covid 19-Consent Form
Covid-19 Questionnaire