Peninsula Orthodontic Group Supplemental Informed Consent Name* First Last Date Of Birth* MM DD YYYY Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?*YESNOAre you/they having shortness of breath or other difficulties breathing?*YESNOHave you/they experienced recent loss of taste or smell?*YESNODo you/they have a cough?*YESNOAny other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?*YESNOAre you/they in contact with any confirmed COVID-19 positive patients?*YESNOIs your/their age over 60?*YESNODo you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*YESNOHave you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)*YESNO Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment. Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.INFORMED CONSENT DURING COVID-19*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 state and federal regulations and recommended 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 grocery store. “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, orthodontic staff and sometimes other patients at all times. I have read and understand the information stated above.Signature of Patient or Legal Guardian*Today's Date: 05/31/2020 This iframe contains the logic required to handle Ajax powered Gravity Forms.