COVID-19 Screening

COVID-19 SCREENING & CONSENT
On the day of any in-person appointment and/or treatment*, please complete the following questionnaire. All information is strictly confidential.

*All medical treatments provided by Beauty Marx Medical Group PLLC
Name*

First NameLast Name
Please answer the following:
Have you traveled outside of the US in the past 30 days?*

YESNO
Have you had contact with anyone who has been symptomatic and/or confirmed with COVID-19 in the last 14 days?*

YESNO
Are you currently experiencing a fever or temperature over 100°F, difficultly breathing or a cough?*

YESNO
Have you had any of the following symptoms in the last 14 days?*

Loss of taste or smellFeverCoughShortness of breathSore throatNone of the Above
Today's Date*

MonthDayYear
Date
I attest that I have answered the above questions truthfully and/or to the best of my knowledge.*

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COVID-19 SCREENING & CONSENT