Your Name

Your Phone Number

Have you had a cough?
YesNo

Have you had a fever?
YesNo

Have you had shortness of breath?
YesNo

Have you been in contact with anyone with these symptoms or anyone who has been diagnosed with COVID-19 in the past 14 days?
YesNo

ACKNOWLEDGEMENT: Draper Orthodontics cannot prevent you from becoming exposed to, contracting, or spreading COVID-19 while utilizing our services or premises. It is not possible to prevent against the presence of the disease. Therefore, if you choose to use Draper Orthodontics' services, you may be exposing yourself to and/or increasing your risk of contracting or spreading COVID-19.

WAIVER OF LAWSUIT/LIABILITY: I hereby forever release and waive my right to bring suit against Draper Orthodontics and its owners, managers, technicians, or other representatives in connection with exposure, infection, and/or spread of COVID-19 related to utilizing Draper Orthodontics' services and premises. I understand that this waiver means I give up my right to bring any claims including for personal injuries, death, disease or property losses, or any other loss, including but not limited to claims of negligence and give up any claim I may have to seek damages, whether known or unknown, foreseen or unforeseen.