New Patient Forms

Patient Name

Do you consent to treatment? Choose one Do you consent to treatment? Choose oneYesNo

Consent Certification Consent Certification By checking this box, I certify that I have read the Supplemental Informed Consent above, and consent to treatment for the above-named patient.

Type your name in this box to sign this document electronically

Relationship to Patient Relationship to PatientSelfParent

Date

Patient Name

Today's Date

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)? Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)? Yes No

Are you/they having shortness of breath or other difficulties breathing? Are you/they having shortness of breath or other difficulties breathing? Yes No

Do you/they have a cough? Do you/they have a cough? Yes No

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? Yes No

Have you/they experienced recent loss of taste or smell? Have you/they experienced recent loss of taste or smell? Yes No

Are you/they in contact with any confirmed COVID-19 positive patients? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment. Are you/they in contact with any confirmed COVID-19 positive patients? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment. Yes No

Is your/their age over 60? Is your/their age over 60? Yes No

Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? Yes No

Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location) Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location) Yes No

Certification Certification By checking this box, I certify that these answers are truthful to the best of my knowledge at the time and date submitted.

Type your name in this box to sign this document electronically.

Relationship to Patient Relationship to PatientSelfParent

Phone