PARENT COVID-19 QUESTIONNAIRE
  • Parent Covid-19 Questionnaire

    Please ensure you sign the form at the bottom and click complete
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  • Patient Acknowledgement of Risk Form

  • To provide a safe environment for our patients and staff, this practice follows the applicable state and federal regulations and protocols for infection control, universal personal protection, and disinfection. However, due to the nature of the procedures we provide, it may not be possible to maintain social distancing between patients, doctors, and staff at all times.

    Patient Acknowledgement

    I acknowledge that I have read the Notice above and that I understand and accept that there is an increased risk of COVID-19 exposure with treatment during the pandemic.

    I understand and accept the increased risk of COVID-19 exposure with treatment at this office.

    I also acknowledge that I could, or may have, exposure to COVID-19 from outside this office and unrelated to my visit here.

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