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WELLNESS SCREENING & DISCLOSURES

Office Protocols:

For 9:00AM or 2:00PM scheduled appointments. The door will remain locked until those exact times.
MASKS ARE OPTIONAL BUT ENCOURAGED.
DO NOT enter the office until 5 min before scheduled appointment or the office staff may ask you leave and wait in your vehicle or outside.
NO UNSCHEDULED SIBLINGS OR FRIENDS are permitted on the office due to the limit of space and for the safety of others.
ONLY ONE ADULT PER FAMILY (NOT PER CHILD) may accompany the patient(s) due to space. If you require more than one adult please contact the office before scheduled appointment so we can schedule accordingly.
No need to call or text that you have arrived for appointment. Just come into the office to be instructed where to sit.

*ATTENTION*

How many children have an appointment on the same day?

Child First Name (1)

Child Last Name (1)

Has this child (1) received a COVID-19 vaccination?

Child First Name (2)

Child Last Name (2)

Has this child (2) received a COVID-19 vaccination?

Child First Name (3)

Child Last Name (3)

Has this child (3) received a COVID-19 vaccination?

Child First Name (4)

Child Last Name (4)

Has this child (4) received a COVID-19 vaccination?

Child First Name (5)

Child Last Name (5)

Has this child (5) received a COVID-19 vaccination?

Child First Name (6)

Child Last Name (6)

Has this child (6) received a COVID-19 vaccination?

Child First Name (7)

Child Last Name (7)

Has this child (7) received a COVID-19 vaccination?

Child First Name (8)

Child Last Name (8)

Has this child (8) received a COVID-19 vaccination?

Does the patient(s) currently have any sickness symptoms?

Dose anyone in the household also have symptoms of illness?

Please explain:

Has the patient(s) or anyone in the household been in contact with someone who has tested positive for COVID‐19 or has had COVID-19 in the last 5 days?

If so, enter date:

Has the patient(s) or household member since been tested for this occurrence? If so, when and what was the result?

If you have answered YES to sickness or postive COVID (contact or tested) or just have general questions our office number is textable.

703-255-2573

I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my or my child's health history which may result in a compromised immune system.

I understand the above protocols are in place for my safety and the safety of other patients and staff.

By signing this document, I acknowledge that the answers I have provided above are true and accurate, and that my appointment may be cancelled or rescheduled.

Signature

Date

Parent or Guardian First Name

Parent or Guardian Last Name

Best Family Cell Phone

Best Family Email

This communication is secure and encrypted for your protection. Once submitted it is sent directly to the office. It may contain protected health information (PHI) that is legally protected from inappropriate disclosure by Privacy Standards of Health Insurance Portability and Accountability (HIPAA) and relevant Virginia Laws.