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Privacy Acknowledgement

I, (Patient Name), hereby acknowledge that Drs. Enoch and Lamei have given me the opportunity to read a detailed notice of their Privacy Practices. Patient/Authorized Representative (if patient is a minor (under 18), form must be signed by a parent or legal guardian
If not signed, please provide a reason why the acknowledgement was not obtained.
In the event I cannot be reached, I, (Patient Name), give permission to Drs. Enoch and Lamei and their staff to speak with family member(s) or companion(s) listed below regarding my orthodontic treatment.
Is it OK to leave results or information on your voicemail?
Patient/Authorized Representative (if patient is a minor (under 18), form must be signed by a parent or legal guardian
Patient/Authorized Representative (if patient is a minor (under 18), form must be signed by a parent or legal guardian
I/We give permission that allows Drs. Enoch and Lamei to change my/my child's personal information on our account as per my request. Permission is also granted to print out our financial ledger unless we notify the office not to without a written notification Patient/Authorized Representative (if patient is a minor (under 18), form must be signed by a parent or legal guardian

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 treatment?

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