COVID-19 Consent Form

Step 1: AAOIC 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.


 By filling out the form below, I certify that the information I provided today is true and accurate the best of my knowledge. My digital signature above confirms I have read and understand all information contained in this document provided to me by Vanlaecken Orthodontics. 

Please Fill Out the Form Below and Submit to Consent to Receive Orthodontic Treatment in the Era of COVID-19*

*By filling out the form above, I certify that the information I provided today is true and accurate the best of my knowledge. My digital signature above confirms I have read and understand all information contained in this document provided to me by Vanlaecken Orthodontics.

COVID-19 Statement

VanLaecken Orthodontics Patients and Families:

We hope you and your family are in good health! 


VanLaecken Orthodontics will be reopening our offices with limited appointment types and a limited number of patients in the clinic at one time beginning May 11th, 2020. Between now and then, our doctors are seeing emergency and urgent care appointments they were not able to treat over the past few weeks. If you had a regularly scheduled appointment next week you will be receiving appointment reminders or cancellations as they apply to your appointment.


Your first appointment back will be assigned to you and sent in a text or email reminder (whichever you have set up with us as your preference). Since we have hundreds of appointments to reschedule, each being important to our team and to your custom treatment plan, we appreciate you doing everything possible to make the assigned appointment time and date work. We will have limited options for rescheduling during this time. We are scheduling each patient in the order they should have been seen prior to COVID-19 closures. After this initial appointment, we will hopefully be able to work with you in scheduling according to your preferences again! Thank you in advance for your understanding as we work to serve your needs and others while also maintaining a safe environment during this unique time. You may notice some changes in the office when it is time for your next appointment:


  • Have you tested or someone close to you tested positive for COVID-19? Have you had a fever, cough, shortness of breath, trouble breathing or persistent pain, pressure, or tightness in the chest? You’ll be asked these questions before entering the clinic. For the protection of our team and your fellow patients, if you are experiencing any symptoms of illness or have been knowingly exposed to COVID-19, please call to reschedule your appointment or visit our website to initiate a virtual appointment.


  • Prior to your first appointment back, each patient (or parent/guardian if the patient is under the age of 18) will need to fill out a one-time AAOIC-required informed consent related to COVID-19. To save time, or if you are unable to attend this first appointment with your child, you may fill it out ahead of time on our website by clicking on the Patient Forms tab or a parent/guardian may accompany the patient to their first appointment back and sign it at the wellness screening table. This form must be completed prior to the patient being seen in the clinic.


  • During this time, we have closed many of the common-use areas of our practice including the brushing station – please brush at home before you come to your appointment.


  • Our check-in process will also look a bit different. When you arrive at the office, you will be greeted prior to entering the clinic and asked the above wellness questions as well as checking the patient’s temperature. After this is completed, we are asking that only patients with a scheduled appointment remain in the waiting room. If a parent/guardian is joining them in the clinic, they will also need to be screened. We are hopeful this requirement will be temporary but are taking the utmost precaution during this time for everyone’s health and safety. Please arrive about five minutes early to complete this process.


  • Your next appointment will automatically be scheduled chair-side with the patient and a text or email will be sent to you according to your appointment reminder preferences that have been set up with our office. A video call can be accomplished on your child’s cell phone during the appointment or you are always welcome to call with any questions after the appointment. Appointments will be managed to allow for social distancing between patients. That might mean that you’re offered fewer options for rescheduling your appointment during this time.  


We are fortunate in orthodontics to have a limited number of appointments that require the use of a high-speed handpiece (and therefore create aerosol spray). The appointments that do require the use of these handpieces will be on a modified schedule for the time being and we have special suction devices to further limit the aerosol as we return to those appointments. Rest assured that the strict sterilization protocols we have always employed will remain in force with additional wipe-downs and precautions being taken according to the guidance of the American Dental Association, the U.S. Centers for Disease Control and Prevention (CDC), the Occupational Safety and Health Administration (OSHA) and the American Association of Orthodontists. Should new infection control guidelines be issued as a result of COVID-19, we will implement them immediately. 


Thank you for being so patient with us during this complicated time. Know that our goal of individualized treatment ending in a beautiful, confident smile for each of our patients has not changed and despite this delay, our entire team remains committed to achieving this in the least amount of time possible for each of our patients. Because a smile is more contagious than any virus!


Together & Forward,

The VanLaecken Orthodontics Team