Name
*
First Name
Middle Name
Last Name
Appointment Date
*
-
Month
-
Day
Year
Date
Email
Confirmation Email
example@example.com
Is there any other family members with an appointment the same day?
Yes
No
Please Specify the number
Family Member 1
First Name
Middle Name
Last Name
Family Member 2
First Name
Middle Name
Last Name
Family Member 3
First Name
Middle Name
Last Name
Family Member 4
First Name
Middle Name
Last Name
Family Member 5
First Name
Middle Name
Last Name
Family Member 6
First Name
Middle Name
Last Name
Family Member 7
First Name
Middle Name
Last Name
Did the patient have close contact with anyone with acute respiratory illness or traveled outside of Sudbury in the last 14 days?
*
Yes
No
Do you (the patient) have a confirmed case of COVID-19?
*
Yes
No
Did you (the patient) had close contact with a confirmed case of COVID-19?
*
Yes
No
Do you currently have any of the following symptoms, or have had any symptoms within the last 14 days?
*
NONE
Fever
New Onset Of Cough
Worsening Chronic Cough
Shortness Of Breath
Difficulty Breathing
Sore Throat
Difficulty Swallowing
Decrease Or Loss Of Sense Of Taste
Decrease Or Loss Of Sense Of Smell
Chills
Headaches
Unexplained Fatigue
Muscle Aches
Nausea / Vomiting
Diarrhea
Abdominal Pain
Pink Eye
Runny Nose
Nasal Congestion
If you experience any of the above symptoms prior to your scheduled appointment and after this form is submitted, I agree to notify the office as soon as possible. I understand that my appointment will be rescheduled as a result.
*
I Understand
I agree that I will bring my own mask or facial covering or otherwise I will be supplied one for $2. I understand that if a parent must accompany the child that the parent will also wear a mask or facial covering. I also agree that the mask will be worn at all times in the clinic or waiting area, unless otherwise instructed.
*
I Understand
I acknowledge that a screening form must be filled out for each appointment scheduled until further notice.
*
I Understand
Any Comments:-
I, myself or the legal guardian of the minor 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 signature.
*
Signature
Clear
Date
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
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