. * 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 been diagnosed with COVID-19 or are waiting on a COVID test? * Yes No Do You have any cold or flu symptoms? * Yes No If you have received vaccine, are you 2 weeks after final dose? * Yes No Have you been exposed to a COVID positive person in the past two weeks? * Yes No 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 (except vaccine question), 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 .