Patient Advisory and Acknowledgment
Receiving Medical Treatment During the COVID-19 Pandemic
Routine
Dear Patient: 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 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 guarantees.Our staff are symptom-free and, to the best of their knowledge, have 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 below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.
Patient Name
*
Signature
*
Clear
Date
-
Month
-
Day
Year
Date
Have you been diagnosed with Covid-19, in the past or currently?
Yes
No
ARE YOU CURRENTLY AWAITING THE RESULTS OF A COVID-19 TEST?
*
Yes
No
DO YOU HAVE A FEVER?
*
Yes
No
DO YOU HAVE ANY SHORTNESS OF BREATH?
*
Yes
No
DO YOU HAVE A DRY COUGH?
*
Yes
No
DO YOU HAVE A RUNNY NOSE?
*
Yes
No
DO YOU HAVE A SORE THROAT?
*
Yes
No
DO YOU HAVE SNEEZING, WATERY EYES, AND/OR SINUS PAIN/PRESSURETHAT IS UNUSUAL AND NOT RELATED TO SEASONAL ALLERGIES?
*
Yes
No
HAVE YOU EXPERIENCED HEADACHES, FATIGUE, OR WEAKNESS?
*
Yes
No
HAVE YOU LOST YOUR SENSE OF TASTE AND/OR SMELL?
*
Yes
No
WITHIN THE LAST 14 DAYS, HAVE YOU TRAVELLED TO ANY FOREIGN COUNTRY?
*
Yes
No
WITHIN THE LAST 14 DAYS, HAVE YOU TRAVELLED WITHIN THE UNITED STATES?
*
Yes
No
IF SO, WHERE?
Submit
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