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.