Form

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****

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.

Print Name of Parent or Guardian/Legally Authorized Representative

Patient/Legally Authorized Signature

Please click on the “sign here”button to sign and then choose “save signature”