Covid-19 Form Does the patient or anyone in the household have fever or have felt hot or feverish recently (14-21 days)?*¿El paciente o alguien en el hogar tiene fiebre o se ha sentido caliente o con fiebre recientemente (14-21 days)? Yes No Is the patient or anyone in the household having shortness of breath or other difficulties breathing?*¿Tiene el paciente o alguien en el hogar dificultad para respirar? Yes No Does the patient or anyone in the household have a cough?*¿El paciente o alguien en el hogar tiene tos? Yes No Any other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?*¿Algún otro sintoma similar a la gripe, como malestar gastrointestinal, dolor de cabeza o fatiga? Yes No Does the patient or anyone in the household experienced recent loss of taste or smell?*¿El paciente o alguien en el hogar ha experimentado una pérdida reciente de sabor o olfato? Yes No Is the patient or anyone in the household in contact with any confirmed COVID-19 positive patients?*¿Está el paciente o alguien en el hogar en contacto con pacientes confirmados positive con COVID-19? Yes No Does the patient or anyone in the household have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?*¿El paciente o alguien en el hogar tiene enfermedades del corazón, enfremedades renales, diabetes o algún trastorno autoimmune? Yes No Has the patient or anyone in the household traveled in the past 14 days to any regions affected by COVID-19?*¿Ha viajado el paciente o alguien en el hogar en los últimos 14 dias a alguna region afectada por COVID-19? Yes No Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as “Coronavirus,” 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 gym, grocery store, or favorite restaurant. “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. Although exposure is unlikely, do you accept the risk and consent to treatment?* Yes No Patient Name* First Last Patient/Parent/Guardian Name* First Last Please sign by typing your Full Name*