COVID-19 FORM

1

Full Name

First Name

Last Name

2

Phone Number

Area Code

Phone Number

3

Have you been in contact with a person with a confirmed case of COVID-19 in the past 14 days?

YESNO

4

Have you returned from overseas in the past 14 days?

YESNO

5

Have you had any of the following symptoms in the past 14 days: sore throat, cough, fever, or difficulty breathing?

YESNO

6

Have you been in close contact or live with someone who has returned from overseas in the past 14 days?

YESNO

7

Have you been in close contact or live with someone who has shown symptoms such as: sore throat, cough, fever, or breathing difficulties?

YESNO

8

If you have answered yes to any of the above questions, please understand we will not be able to proceed with the appointment at this time.

Please direct message me and let me know, we will reschedule for a later date. I apologize in advance for the inconvience this may cause, but better safe than sorry!

9

BY COMPLETING THIS FORM AND SIGNING THIS ACCEPTANCE I AGREE THAT:

Corona Virus (COVID-19) has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. This results in placing many preventative measures to reduce the spread of COVID-19. However, while taking all possible precautions, I cannot guarantee that you will not become infected with COVID-19.

By signing this agreement, I acknowledge the contagious nature of COVID-19 and by attending an appointment, I do so at my own risk.

I do not currently have any symptoms of COVID-19
I have not knowingly been in contact with confirmed case of COVID-19 in 14 days.
I have read and answered the questions above truthfully
I ahve read, agree to, and have signed the waiver

10

Signature

Clear

11

Name

First Name

Last Name

12

Date