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C-Wellness Form ‐ PATIENT DISCLOSURES
Patient First Name
Patient Last Name
Patient Date Of Birth
****PLEASE COMPLETE AND RETURN THIS FORM
BY THE EVENING PRIOR TO YOUR VISIT
****
**If you answered "YES," please explain in the box below AND CALL OUR OFFICE IMMEDIATELY at 413-587-0888**
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)?
Print Name Of Patient/ Parent or Guardian(if Minor)/Legally Authorized Representative
Relationship If Signed On Behalf Of Patient
By signing this document, I acknowledge that the answers I have provided above are true and accurate.
Patient/Legally Authorized Representative Signature Click button below to sign. Then click Save Signature. Then click Submit.
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