Form

COVID‐19 PATIENT DISCLOSURES

Patient First Name

Patient Last Name

Patient Date of Birth

Has the patient or any member of the patient's household had any flu-like symptoms in the past 14 days such as fever, cough, sore throat, or runny nose?

Has the patient or any member of the patient's household been in contact with anyone who has tested positive for COVID-19 in the past 14 days?

Has the patient been tested for COVID‐19 in the past 10 days?

Why was the patient tested for COVID-19?

Were the most recent COVID-19 test results positive?

I fully understand and acknowledge the above information, risks and cautions and have disclosed to my provider any other conditions in my health history.

By signing this document, I acknowledge that the answers I have provided above are true and accurate.

I am the patient's:

Parent First Name

Parent Last Name

Legal Guardian First Name

Legal Guardian Last Name

Patient First Name

Patient Last Name

Parent Signature

Legal Guardian Signature

Patient Signature

Date