To our valued patients, thank you for your support and patience in the past weeks as our office has been closed in compliance with our Governor’s directives during the peak of the COVID-19 pandemic. We are very much looking forward to resuming orthodontic care in the safest possible way for both patients and staff. Part of that initiative includes the attached Wellness Screening and Treatment Consent that we request is returned prior to EACH APPOINTMENT. Please call or email the office if you have any questions, and we will see you soon! . * Required . Please fill out entire form and then press SUBMIT. Thank you! Wellness Screening & Treatment Consent Name * Email * 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 by airplane or cruise ship (in the past three weeks) * Yes No Traveled to any of the following states with a high rate of infection in the past two weeks? None Alabama Arizona Arkansas California Delaware Florida Georgia Idaho Iowa Kansas Louisiana Mississippi Nevada North Carolina Oklahoma South Carolina Tennessee Texas Utah 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 Submit If you are human, leave this field blank. .