. * Required . Please fill out entire form and then press SUBMIT. Thank you! Wellness Screening & Treatment Consent Name * Email * Date and Time of Next Appointment * Have you received a second dose of the vaccine? * Yes No If so, what was the exact date of your second dose? In the last 14 days, has the patient (or any member of the household) had any of the following? Fever (over 99.6 degrees F) * Yes No Coughing * Yes No Shortness of breath or trouble breathing * Yes No Persistent pain, pressure or tightness in chest * Yes No Loss of sense of smell * Yes No Travel outside of the United States (in the past two weeks) * Yes No Has the patient, a family member, or any known close contact had any of the following occur? Diagnosis of COVID-19 infection, or any other communicable disease * Yes No Waiting on results of test for COVID-19 infection * Yes No Symptomatic but unable to get tested for COVID-19 * Yes No If the patient, family member, or close contact has been diagnosed with COVID-19 infection, when did that occur? If the answer to any of these questions changes before the appointment, I agree to notify Dr. Stone's office as soon as possible. Also, if the answer is yes to any of the previous questions, I understand I will be asked to reschedule the appointment. * Yes, I Understand Treatment Consent: Please be assured that our office has always met or exceeded the requirements set forth for sterlilzation and infection control from the CDC and OSHA, and will continue to do so. However, it is possible to contract COVID-19 infection (or any other communicable disease) in any public space. Our office will provide for socially distant appointment scheduling, and also has added a number of new technologies and techniques to the practice to enhance our level of safety. However, due to the nature of orthodontic treatment, social distance is not possible between the orthodontic patient and clinical staff/doctor. Exposure to communicable disease is unlikely but possible. Clicking "yes" below indicates that the risks involved are accepted, and that consent is given for treatment to be provided by the office of Dr. Stone. * Yes, I consent to dental treatment If you are human, leave this field blank. Submit .