COVID-19 Informed Consent Form

To our Mountcastle Family:

As we follow the impact of the Novel Coronavirus (COVID-19) and in accordance with the Centers for Disease Control (CDC) and American Society of Plastic Surgery, we want to outline the measures we are taking to enhance the health and safety protocols in and around our practice. Your safety and the safety of our team is our primary concern. Until further notice, please respect and adhere to the following enhanced health and safety protocols:

Prior to a scheduled appointment:

• Please call to reschedule your appointment if the patient or anyone in the family has had a fever, shortness of breath, dry cough, runny nose, or sore throat
• Please keep in mind that only one person may accompany a patient to his/her appointment. To minimize the number of people in our office we respectfully insist that you do not bring siblings, friends, or relatives to your family member’s appointment.

When you arrive at the office:

• Our reception area is limited to 1 patient at a time. Please call our office or look through the glass door prior to entering. When we are ready for you, we will call you so you can immediately be taken into our treatment area. One person may accompany a patient to his/her appointment if needed but prefer the patient come alone.

Prior to entering the office you will be asked the following questions:

• Have you or anyone in your family had a fever, shortness of breath, dry cough, runny nose, or sore throat?
• Have you or someone in your family traveled outside the state or outside the country in the last 14 days?
• Has the patient taken any medications to reduce fever in the last 8 hours?
• This includes aspirin, ibuprofen, naproxen, and acetaminophen

We ask that you be truthful and candid with your answers. If you or any family member have a fever or even mild flu-like symptoms, please do not come to the office. Please call us and we will gladly accommodate a new appointment date.

EVERY PERSON entering the office will be required to:

• Wear a mask that covers both the mouth and the nose
• Have their temperature screened with a thermometer
• Any individuals with a temperature over 100.4°F will not be permitted to enter the office
• Wash their hands for 30 seconds with soap and water prior to the visit at home or in the hall bathroom
• Observe the 6 feet social distancing recommendation when possible

With regard to scheduling, rescheduling, or cancelling appointments:

• Our team has been working together to lighten the schedule. Please respect the appointment time you were given. We are making every attempt to stagger appointments and limit the number of patients in the office at any given time.
• Please respect our policy of “by appointment only”. We will not be accepting “walk-in” patients at this time.

As a reminder our clinic remains a very safe space to continue to administer care. We are constantly disinfecting our facility and equipment. All team members are taking all universal precautions recommended by the CDC and the American Society of Plastic Surgery to maintain a clean and safe environment.

In addition to our standard levels of sterilization and disinfection, our team is disinfecting common areas throughout the day including the front desk, patient rooms, and all door knobs.

Thank you for your understanding and adherence to these health and safety protocols. To protect your families and ours, we will continue to closely monitor the COVID-19 situation and follow local, state and federal guidelines. We continue to take this day by day and will make updates and changes as needed.

Informed Consent – COVID-19

You are receiving surgical/nonsurgical care during the pandemic events of COVID-19 National Emergency. Please be advised that there may be increased risk of exposure from doctors, staff, other patients, and the treatment facility. We are taking precautions to limit the spread of this disease, but there is still a possibility of transmission.

I understand that COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not, given the current limits on virus testing. Dental/Orthodontic procedures create water spray which is how the disease is spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the COVID-19 virus.

I knowingly and willingly consent to have treatment completed during the COVID-19 pandemic. I am the parent, guardian, or personal representative of the patient and there are no court orders now in effect that prevent me from signing this consent. I do hereby acknowledge the health risks of the COVID-19 virus during this National Emergency and I willfully request and authorize the doctors and staff at NOVA Pediatric Dentistry & Orthodontics to perform any necessary dental and/or orthodontic services. I will be responsible for any charges incurred for my child for treatment.