Patient Disclosure Form
Each patient will need to complete this form no later than one hour prior to each appointment at the Coppell clinic or Dallas satellite location. Contact the main clinic (469.763.9459) or your assigned clinician if you have any questions or to notify Holland of symptoms noted on this form. Your appointment will be cancelled if you, or anyone you have come in contact with, has symptoms listed on this form. Telehealth services can be offered if your appointment is cancelled.
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Email *
Patient Name *
In the past 14 days, has the patient or anyone in the patient’s household come in close contact with anyone who has tested positive for COVID-19? *
Does the patient or anyone in the patient’s household have any of the following symptoms? Fever above 99.6 degrees or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and/or diarrhea. *
Has the patient traveled outside of the United States in the last two weeks? *
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