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


  • 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.

  • 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. 

  • Clear
  • Should be Empty:
Jotform Logo
Now create your own Jotform - It's free! Create your own Jotform