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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”
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