To proceed with receiving care, I confirm and understand the following (Check all seven Boxes) Please enable JavaScript in your browser to complete this form.FormI understand my treatment may create circumstances, such as the discharge of respiratory droplets or person-toperson contact, in which COVID-19 can be transmitted.I understand that I am opting for an elective treatment that may not be urgent or medically necessary, and that I have the option to defer my treatment to a later date. However, while I understand the potential risks associated with receiving treatment during the COVID-19 pandemic, I agree to proceed with my desired treatment at this time.I understand due to the frequency of appointments with patients, the attributes of the virus, and the characteristics of procedures, I may have an elevated risk of contracting COVID-19 simply by being in a health care office.I confirm I am not experiencing any of the following symptoms of COVID-19 that are listed below: Fever, Shortness of Breath, Dry Cough , Runny Nose , Sore Throat , Loss of Taste or SmellI understand travel increases my risk of contracting and transmitting the COVID-19 virus. I verify that I have NOT in the past 14 days I have not traveled: 1) Outside of the United States to countries that have been affected by COVID-19; or 2) Domestically within the United States by commercial airline, bus, or train.I am informed that you and your staff have implemented preventative measures intended to reduce the spread of COVID-19. However, given the nature of the virus, I understand there may be an inherent risk of becoming infected with COVID-19 by proceeding with this treatment. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment and give my express permission to you and the staff at your offices to proceed with providing care.I have been offered a copy of this consent form.Full NameDateSubmit
