COVID-19 QUESTIONNAIRE - MACKENZIE HUGHES VISITOR - March 2022

COVID-19 QUESTIONNAIRE

MACKENZIE HUGHES VISITOR
All visitors must complete this questionnaire prior to entering the Mackenzie Hughes LLP office located at 440 South Warren Street, Suite 400, Syracuse, NY 13202. All unvaccinated visitors are required to wear a face mask when entering the Galleries building. Face masks are optional for vaccinated visitors.
Name *

First Name Last Name
Contact number for COVID-19 contact tracing (with area code) *
1.Have you been in close or proximate contact in the past 14 days with anyone who has tested positive for COVID-19? *
Due to your response of “Yes” to this question, please contact your attorney to reschedule your appointment.
2.Have you been in close or proximate contact in the past 14 days with anyone who has or had symptoms of COVID-19? *
Due to your "Yes" response, please contact Tim Whelan at 315-233-8271.
3. Have you had a positive COVID-19 test in the past 14 days? *
Due to your response of “Yes” to this question, please contact your attorney to reschedule your appointment.
4. Have you experienced any symptoms of COVID-19 in the last 14 days? Symptoms include:
a. cough (new cough or change in your cough not related to a chronic condition) *
Due to your "Yes" response, please contact Tim Whelan at 315-233-8271.
b. new shortness of breath or difficulty breathing *
Due to your response of “Yes” to this question, please contact your attorney to reschedule your appointment.
c. fever *
Due to your response of “Yes” to this question, please contact your attorney to reschedule your appointment.
d. chills *
Due to your "Yes" response, please contact Tim Whelan at 315-233-8271.
e. muscle pain *
Due to your response of “Yes” to this question, please contact your attorney to reschedule your appointment.
f. sore throat *
Due to your response of “Yes” to this question, please contact your attorney to reschedule your appointment.
g. new loss of taste or smell *
Due to your response of “Yes” to this question, please contact your attorney to reschedule your appointment.
Please contact Tim Whelan at (315)-233-8271 if you experience any of the COVID-19 symptoms in the next 14 days.
Due to your "Yes" response to one of the questions above, you are not eligible to submit this questionniare. You must contact your attorney to reschedule your appointment.
This field will auto-generate and cannot be changed.

Month Day Year
Date
This field will auto-generate and cannot be changed.

: Hour Minutes AM/PM Option
Should be Empty: