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Wellness Screening & Treatment Consent
Have you received a second dose of the vaccine? *
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) *
Coughing *
Shortness of breath or trouble breathing *
Persistent pain, pressure or tightness in chest *
Loss of sense of smell *
Travel outside of the United States (in the past two weeks) *
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 *
Waiting on results of test for COVID-19 infection *
Symptomatic but unable to get tested for COVID-19 *
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. *
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. *