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
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.