I confirm that I am not presenting any of the following symptoms of COVID-19 listed below:
Do you have a cough?YesNo
Do you have a fever now or have you in the past 14-21 days?YesNo
Have you come in contact with any confirmed COVID-19 positive patients in the last 14 days?YesNo
Are you experiencing shortness of breath or difficulty breathing?YesNo
Are you experiencing other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?YesNo
Have you experienced recent loss of taste or smell?YesNo
Are you over the age of 60?YesNo
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?YesNo
Have you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)YesNo
I have been informed that the office has implemented preventative measures intended to reduce the spread of Covid-19. I hereby acknowledge that by submitting this wellness form, I am agreeing to all current or future policies as it relates to Covid-19, and I give my permission for your team to proceed with providing care. Check here if you accept these terms.
or give us a call at 516-671-0817.
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