COVID19 Waiver and Guidelines

Patient's Name*

First Middle Initial Last

Is the patient under 18 years of age?**

No
Yes

Guardian's First Name

Guardian's Last Name*

Email*

To do our part in preventing the spread of COVID-19 in our community and workplace, we are restricting access to this facility for anyone who may have recently been exposed to the virus. Please read this carefully.

By entering this facility, you are affirming and attesting that:

(a) You have not in the last 14 days had any close contact with anyone who is either confirmed or suspected of being infected with COVID-19, including anyone who was experiencing or displaying any of the known symptoms of COVID-19 (which are listed in item (c) below); AND

(b) You have not in the last month traveled to a restricted area that is under a Level 2, 3, or 4 Travel Advisory according to the U.S. State Department (including China, Italy, Iran, and most of Europe); AND

(c) You do not currently and you have not in the last 14 days experienced or displayed, any of the following symptoms:

Elevated temperature or fever of 100.4 F or higher,
Cough,
Shortness of breath and/or difficulty breathing,
Loss of smell and/or taste,
Fatigue, muscle aches, chills, shaking, or
Persistent headaches.

If you answered YES to any of the above statements, you may NOT enter this building.

Signer's Name*

First Last

Please type in the name of the patient or the guardian, if patient is under 18 years of age, to sign the document.

COVID19 Waiver and Guidelines

Recent News

Patients