MiBella - COVID-19 Consent Form

MiBella - COVID-19 Consent Form
Covid-19 is a pandemic. If you are experiencing signs or symptoms, have traveled out of the country in the last 14 days, have been around someone who has traveled out of the country in the last 14 days, or have been exposed to someone diagnosed with COVID-19 or the flu please reschedule your appointment.

At MiBella, we are doing everything we can to keep our patients and staff safe. Let us know if you have any questions.

Signs and symptoms of COVID-19 may appear 2 to 14 days after exposure and can include the symptoms below.
If are you presently experiencing:
Please check all that apply

No symptomsFeverCoughShortness of breath or difficulty breathingTirednessAchesRunny noseSore throat
If you are having symptoms, please explain below
Signature*

Clear
Date*

MonthDayYear
Date
Printed name of signee: required*
I will immediately notify MiBella Wellness Center, if I test positive for COVID-19 within 3 weeks of my in-office visit.
Should be Empty: