Please answer the following questions the day of your appointment.

 

First and Last Name
(DD/MM/YYYY)
You understand that by coming to the office, you are assuming the risk of exposure to the coronavirus (or other public health risk). Exposure to Covid-19 may result in adverse health effects that may require hospitalization, intubation/ventilator support, long-term health related risks (i.e lung dysfunction), or even death.