Consent Form

Name *

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RISK ASSESMENT AND CONSENT – COVID-19 PANDEMIC ORTHODONTIC TREATEMENT ONLY patients with approved appointments and completed compulsory documents will be permitted onto the premises. To comply with social distancing regulations only parents of patients who are 10 years and younger will be allowed to enter the practice with the patient, limited to one parent. Unfortunately no other parents will be allowed to enter the practice unless requested by us. NB!! The following preventative and protective measures have been put in place: • Controlled access • Sanitizing stations (hands & feet) • Screening all patients and staff (temperature control) • Virtual appointments • Appropriate PPE Please complete the following:

My details, as the patient / parent / guardian of the patient:

Patient
Parent
Guardian

Date of Birth:

Identity Number: (required) *

Residential Address:

Contact Number / Email Address: (required) *

1. Have you travelled in the last 21 days?

2. Have you been in contact with any sick person during the last 21 days?

3. Did you provide any health care or received any health care during the last 21 days?

4. Did/Do you have any flu like symptoms (cough, difficulty breathing/sore throat, lost of taste and smell) or had/have a high temperature?

5. Any Other Relevant Information:

Accept T&C *

I understand the 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 per patient/person.

I agree and undertake to immediately notify the practice (by email to ontvangs@drpretorius.co.za) of any change in my or the patient's status, including diagnosis with Covid19 and/or quarantine and/or isolation.

I hereby consent to having my and the patient's temperature taken by a practitioner prior to, during, and after any consultation, and will provide any follow up information in writing if reasonably requested by a practitioner.

I affirm that all the above statements apply equally to myself, insofar as I am not the patient and I am accompanying the patient to the consultation.

I accept, acknowledge and agree that the practice may decline to undertake a consultation if, in its reasonable professional opinion, exercising its ethical, professional and moral obligations to its other patients, practitioners and the community at large, it believes that:

in doing so, the patient will expose any other person whatsoever , whether directly and/or indirectly, to infection with the Covid19; and/or
the patient is presenting with any of the symptoms listed and/or the patient's temperature, immediately prior to or during a consultation, is above 37.2 degrees celsius.
and in this regard, I waive any ethical and professional complaints against the practice and Dr LM Pretorius.

I am duly authorized to complete this form and give the consents, warranties, assurances, undertakings and the like, and indemnify the practice and the practitioners accordingly.

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