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:
YESNO
YESNO
YESNO
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