Patient Advisory and Acknowledgement Receiving Medical Treatment During the COVID-19 Pandemic
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 the 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
Our staff is symptom-free and, to the best of their knowledge, has 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
For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.
HAVE YOU BEEN DIAGNOSED POSITIVE FOR THE COVID-19 VIRUS AT ANY TIME?
ARE YOU CURRENTLY AWAITING THE RESULTS OF A COVID-19 TEST? YES / NO
HAVE YOU BEEN EXPOSED TO ANYONE WHO HAS BEEN DIAGNOSED WITH COVID-19 IN THE
HAVE YOU VISITED OR RECEIVED TREATMENT IN A HOSPITAL, LONG-TERM CARE FACILITY, OR
OTHER HEALTHCARE FACILITY IN THE PAST 30 DAYS? YES / NO
ARE YOU COVID19 VACCINATED? YES / NO
IS EVERYONE IN YOUR HOUSEHOLD (ABOVE THE AGE OF 12 YEARS) VACCINATED?