COVID-19 Pandemic Treatment Consent Form First Name* Last Name* Email* Mobile # **I knowingly and willingly consent to have treatment completed during the COVID-19 pandemic. I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it, and who does not given the current limits in virus testing. Surgical and non-surgical procedures can create water spray. It is unclear as to how long the ultra-fine nature of the spray may linger in the air, which can transmit the COVID-19 virus.1. Have you experienced cold and/or flu like symptoms in the past 14 days? Yes No 2. Have you been in close contact and/or cared for someone who has tested positive for COVID-19 in the past 14 days? Yes No 3. Have you traveled outside the United States in the past 14 days to countries that have been affected by COVID-19. Yes No 4. Have you traveled domestically with the United States by commercial airline, bus or train within the last 14 days. Yes No 5. Do you currently have any of the following symptoms of COVID-19 listed below: Yes No • Fever • Shortness of Breath • Loss of Sense of Taste or Smell • Dry Cough • Runny Nose • Sore Throat Signature for Consent*
