Covid screening form

Covid screening and consent

Please complete before attending your appointment
This screening is to help protect the practitioners who work in the office as well as all of the patients who enter the premises. Some of our patients are within the high risk group and we are trying to make our space as safe as possible for everyone involved.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com

Covid screening and consent