COVID-19 Consent

This patient disclosure form seeks information from you that we must consider before making treatment decisions during the circumstances of the COVID-19 virus.

Do you have a fever or above normal temperature?*

Yes
No

Have you experienced shortness of breath or had trouble breathing?*

Yes
No

Do you have a dry cough?*

Yes
No

Have you recently lost or had a reduction in your sense of smell?*

Yes
No

Have you recently lost or had a reduction in your ability to taste?*

Yes
No

Do you have a sore throat?*

Yes
No

Have you had contact with any KNOWN positive COVID-19 patient?*

Yes
No

Have you tested positive for COVID-19?*

Yes
No

Have you been tested for COVID-19 and are awaiting results?*

Yes
No

Have you traveled within the United States by air or cruise in the past 14 days?*

Yes
No

Have you traveled within the United States by air, bus or train within the past 14 days?*

Yes
No

Name*

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By signing this document, I acknowledge that the answers I have provided above are true and accurate.

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