Patient Advisory and Acknowledgment

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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 *

First Name, Last Name *

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)? *

Yes

Are you/they having shortness of breath or other difficulties breathing? *

yes

Do you/they have a cough? *

Yes

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? *

Yes

Have you/they experienced recent loss of taste or smell? *

Yes

Are you/they in contact with any confirmed COVID-19 positive patients? *

Yes

Date *

YYYY

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