COVID Pre-Screen

By attending my appointment…

I agree that I am not currently experiencing any of these symptoms:

  • Cough
  • Shortness of breath or difficulty breathing
  • Fever
  • Chills
  • Sore throat
  • New loss of taste or smell

Please note: Other less common symptoms have been reported, including gastrointestinal symptoms like nausea, vomiting, or diarrhea.

I agree that I have not:

  • Tested positive for Covid-19
  • Knowingly been exposed to someone with Covid-19
  • Been in an area where social distancing was not properly observed
  • This field is for validation purposes and should be left unchanged.