Coronavirus

Dear Patient:
You have come to our office today for a routine medical evaluation and/or treatment that will be done during the
COVID-19 pandemic. Please be advised of the following:
While our office complies with State Health Department and the Centers for Disease Control and
Prevention infection control guidelines to prevent the spread of the COVID-19 virus, we cannot make
any guarantees.
Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus.
However, since we are a place of public accommodation, other persons (including other patients)
could be infected, with or without their knowledge.
In order to reduce the risk of spreading COVID-19, we have asked you a number of “screening” questions below.
For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.

Name

Have you been diagnosed or tested positive for COVID19 at any time? *

Yes No

Are you currently awaiting the results of a COVID19 test? *

Yes No

Have you been in close contact with a confirmed case of coronavirus?

Yes No

Do you have a fever? *

Yes No

Do you have shortness of breath? *

Yes No

Do you have a dry cough? *

Yes No

Do you have a runny nose? *

Yes No

Do you have a sore throat? *

Yes No

Do you have sneezing, watery eyes, and/or sinus pressure or pain that is unusual and not related to seasonal allergies? *

Yes No

Have you experienced headache, fatigue or weakeness? *

Yes No

Have you lost your sense of taste or smell? *

Yes No

Within the last 14 days have you travelled out of the country?

Yes No

Within the last 14 days have you travelled out of the state of MD?

Yes No

If so, where?

By submitting I hereby confirm that the information I have given above is true, and that I will comply with the terms and conditions outlined above.

Signature

Clear

Patient Advisory and AcknowledgmentReceiving Medical Treatment During the COVID-19 Pandemic