We are taking measures to promote social distancing and prevent further transmission
Please indicate if any of the following applies to you:
Have you experienced ANY COVID-19 related symptoms within the last month, such as :
If any of the above applies to you, please let our staff know IMMEDIATELY.
WE RESERVE THE RIGHT TO RESCHEDULE YOUR APPOINTMENT
Please print your name and sign below indicating you have read this document in its entirety and have answered them honestly to the best of your knowledge.
By submitting this FORM you are indicating you have answered the questions honestly and truthfully.