This should be filled out by a patient’s legal guardian!

If you’re an adult patient or a minor filling this out for yourself, please continue. We’ll be notified to get further consent from your legal guardian.

If you’re under the age of 13, do not continue. Please contact our office.

Get Started:

As with any illness, anyone can be exposed to COVID-19 at any time or place. We have always followed all recommended guidelines, laws and disinfection protocols in our office. Even with our careful attention, the chance remains that you could be exposed in our office, just as you might be anywhere. We’ve taken significant measures to keep you safe, however, it’s not always possible to maintain a constant distance between the patient, our office staff, and sometimes other patients.
By signing the document above, and filling out this form, I confirm that I understand the questions presented to me and that I’ve answered all these questions honestly. I also understand that these answers may result in being asked to reschedule today’s appointment. I confirm that I am not a minor, am the legal guardian of this patient, or am an adult patient filling this out for themselves.

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