Name

First Name Last Name

Birth Date

Month Day Year

Email

example@example.com

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

A weak immune system can put you at greater risk for contracting COVID-19. Please select the ones that apply.

Please disclose any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus.

Have you tested positive for COVID-19?

Yes No

Have you been tested for COVID-19 and are awaiting results?

Yes No

Have you been in contact with someone who has tested positive for COVID-19?

Yes No

Have you traveled abroad by air or cruise ship in the past 14 days?

Yes No

Please select the signs or symptoms that you are currently experiencing or have experienced within the last 15 days.

Further Comments

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 health history which may result in a compromised immune system.
By signing this document, I acknowledge that the answers I have provided above are true and accurate.

Date

Signature

Clear

Facial Consent for COVID-19