Expressions COVID Consent Form

Name*

First NameMiddle NameLast Name
Appointment Date*

MonthDayYear
Date
YesNo
Please Specify the number
Family Member 1

First NameMiddle NameLast Name
Family Member 2

First NameMiddle NameLast Name
Family Member 3

First NameMiddle NameLast Name
Family Member 4

First NameMiddle NameLast Name
Family Member 5

First NameMiddle NameLast Name
Family Member 6

First NameMiddle NameLast Name
Family Member 7

First NameMiddle NameLast Name
In the last 10 days have you experienced any of the symptoms below?
- If you are fully vaccinated and not immune-compromised and experienced the
  symptom(s) over 5 days ago and the symptoms have been improving for over 24 hours,
- If you are unvaccinated or immune-compromised and experienced the symptom(s) over 10 days ago and the symptom(s) has been improving for over 24 hours,
- If you received a COVID-19 and/or flu vaccination in the last 48 hours and are
  experiencing only mild fatigue, muscle aches, and/or joint pain that only began after vaccination,
- Symptoms should not be chronic or related to other known causes or conditions. The symptoms listed here are the symptoms most commonly associated with COVID-19:
  - fever and/or chills
  - cough or barking cough (croup)
  - shortness of breath
  - decrease or loss of smell or taste
- Two or more of:
  - fatigue
  - muscle aches/joint pain
  - nausea/vomiting, and/or diarrhea
  - sore throat
  - runny or stuffy/congested nose
  - headache
YesNo
YesNo
Do any of the following apply?
- You live with someone who is currently isolating because of a positive COVID-19
  test
- You live with someone who is currently isolating because of COVID-19 symptoms
- You live with someone who is waiting for COVID-19 test results
- In the last 10 days, you have you been identified as a “close contact” of someone who currently has COVID-19 AND you are not fully vaccinated or you are immune compromised
YesNo
I Understand
I Understand
Any Comments:-
Signature*
I, the patient or the legal guardian of the minor patient named above, acknowledge that the information I have provided is true to the best of my knowledge. Please type your name and provide with your signatures.*
Date

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Date
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