Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or flu, you may be exposed to COVID-19, also know as the “Coronavirus,” at any time or in any place. Be assured that we have always followed state and federal regulations as recommended as well as 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 the use of our 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, optometrist, optometrist staff, and sometimes other patients at all times.Although exposure is unlikely, do you accept the risk and consent to treatment?*YesNoYour Name*Patient/Parent Signature*Date Date Format: MM slash DD slash YYYY If you have been exposed to a communicable disease, you may spread the disease to the optometrist, optometrist staff, and other patients/parents in the practice. Therefore, prior to each appointment, we will be asking the following questions to reduce chances of transmission: Do you, your child, others accompanying you to today's appointment, or anyone you have recently been in contact with have any of the following symptoms?Fever (defined as above 99.6 degrees)?*YesNoCough?*YesNoShortness of breath and/or trouble breathing?*YesNoPersistent pain, pressure or tightness in the chest?*YesNoHave you, your child, others accompanying you to today's appointment or anyone you have recently been in contact with tested positive for or been diagnosed as having COVID-19 or any other communicable disease?*YesNoProvide dates of illness:*I understand that if my answer to any of these questions is yes, I may be asked to reschedule today's optometrist appointment to a later date.SignatureDate Date Format: MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.