We are taking measures to promote social distancing and prevent further transmission

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Please indicate if any of the following applies to you:

Have you been out of the country within the last month?
Have you come in DIRECT contact with anyone who has been out of the country in the last month?
Have you come in DIRECT contact with anyone confirmed or suspected to have COVID-19?

Have you experienced ANY COVID-19 related symptoms within the last month, such as :

Fever
Dry Cough
Sore Throught
Chills
Muscle Pain
Shortness of Breath or Difficulty Breathing
New Loss of Taste or Smell

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.