COVID-19 SCREENING QUESTIONNAIRE

In order to prevent the spread of the coronavirus and reduce the potential risk of exposure to our workforce, we are asking everyone to complete and submit this questionnaire. Please respond to each of the following questions truthfully and to the best of your ability. Your participation is important to help us take precautionary measures to protect you and our employees.

Screening Questions

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I agree to notify the practice if within 10 days I become ill with COVID-19 symptoms or test positive for COVID-19.
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