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Wellness Form - PATIENT DISCLOSURES

****PLEASE COMPLETE AND RETURN THIS FORM
BY THE EVENING PRIOR TO YOUR VISIT****
 

 
Have you experienced any of the following symptoms in the last 5 days that is not something normal for you: cough, runny nose, sore throat, fever, vomiting (or any other symptom)?


 
If you answered "YES,
Please CALL OUR OFFICE
413-587-0888
Please fill in this section only if you are signing this form on behalf of someone other than yourself.
Patient/Legally Authorized Signature

Signature Pad

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