Supplemental Informed Consent Questionnaire With community transmission of communicable diseases, you could be exposed anywhere to infectious diseases including, but not limited to Covid-19 (also called Coronavirus). Our optometry office is following the State and Federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of communicable diseases. However, it is possible that these precautions will not always be successful in blocking the transmission of these diseases. Social distancing nationwide has reduced the transmission of Covid-19, however it is not possible to provide vision care and eye exams with social distancing between the patient, Doctor, staff and sometimes, other patients. By presenting yourself or your child for vision care and/or an eye exam, you assume and accept the risk that you or your child may inadvertently be exposed to a communicable disease. If you have been exposed to a communicable disease prior to your eye appointment, you may spread the disease to the Doctor, staff and to other patients/parents in the practice. Therefore, prior to each appointment, we require you to answer the following questions:Have you, your child, or others accompanying you to today’s appointment been tested positive for or been diagnosed as having Covid-19?* Yes No If so, when? Current SymptomsDo you, your child, or others accompanying you to today’s appointment have:A Fever?* Yes No A Cough?* Yes No Shortness of Breath and/or Trouble Breathing?* Yes No Persistent pain, pressure or Tightness in the chest?* Yes No If any of you have any of these symptoms or have recently tested positive for or been diagnosed with Covid-19, you will be asked to reschedule your orthodontic appointment.Do you acknowledge and accept the risk of exposure in our orthodontic office to a communicable disease, included but not limited to Covid-19, and consent to treatment?* Yes No Signer's Name* First Last Patient's Name (if different than signer) First Last Patient/Parent's Signature*Date* MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.