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COVID-19 Consent Form
Due to the new variant of Covid-19, we have to tighten our safety measures. If your answer is Yes to any of the questions below, please cancel or change your appointment.
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First Name
*
Your answer
Last Name
*
Your answer
Have you or any of your family members been told to stay home, self-isolate or self-quarantine in the last 14 days?
*
Yes
No
Have you or any family members had any Covid symptoms in the last 14 days? (cough, temperature, loss of taste or smell, unusual fatigue or shortness of breath)
*
Yes
No
Have you or any of your family members had a positive test for COVID-19 in the past 14 days?
*
Yes
No
Date:
*
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YYYY
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