Please answer the following questions the day of your appointment.

 

First and Last Name
(DD/MM/YYYY)
** Examples include: A positive test from a co-worker that you have been around in the last 14 days or being around a family member with flu/cold like symptoms in the last 14 days.
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.