COVID-19 Patient Disclosure

Here are some instructions you should read prior to your appointment:

  1. Please confirm your appointment 24 hours prior. If we do not hear from you, we will cancel your appointment and schedule another patient at the allocated time.
  2. Please sign the waiver below at least 1 hour before your appointment
  3. There will be a closed waiting room. We are only allowing active patients inside the office. Unless the child is under 12. In that case, only one adult will be allowed inside. Do not drop off the kids and leave them unattended.
  4. Text us when you arrive to the parking lot! We will check you in and let you know when the doctor is ready to see you.
  5. You will be required to use your own mask to be able to enter to the office.
  6. Temperature checks will be done in the entrance by our ambassadors. Anyone over 100 degrees will not be allowed inside.
  7. Please use the hand sanitizer when you come in
  8. Brushing stations and restrooms will be closed. Please brush and floss at home
  9. When the appointment is finished, we will text you. Our ambassadors will walk minors to the car.

Please be patient. This is new to us too, and we are trying our best to see our patients in a safe and friendly environment, keeping in mind all the State OSHA and Federal guidelines we are adhering to.

This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID‐19 virus. A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID‐19. Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us. It is also important that you disclose to this office any indication of having been exposed to COVID‐19, or whether you have experienced any signs or symptoms associated with the COVID‐19 virus.


  • Date Format: MM slash DD slash YYYY
  • 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 at any time or in any place. Be assured that we have always followed the state and federal regulations and recommend 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, treatment specialists and sometimes other patients at all times.

  • I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system.

    By typing your name below, you are acknowledging that the answers provided above are true and accurate.

Plantation: 954-452-9988

West Pembroke Pines: 954-436-0502

East Pembroke: 954-251-2717