Patient Advisory and Acknowledgment
Dear Patient:

While our office complies with State Health Department and the Centers for Disease Control and Prevention infection control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees.

Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge.

In order to reduce the risk of spreading COVID-19, we have asked you a number of “screening” questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.
Email address *
Have you been diagnosed with COVID 19? *
Required
If you answered yes when were you diagnosed?
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Do You Have A Fever? *
Required
Do You Have Any Shortness of Breath? *
Required
Do you have any loss of taste? *
Required
Do You Have a Dry Cough? *
Required
Do You Have a Runny Nose? *
Required
Do You Have a Sore Throat? *
Required
Within the Last 14 Days, Have You Traveled to Any Foreign Country? *
Required
Within the Last 14 Days, Have You Traveled to Within the United States? *
Required
Name *
Date *
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