Pre-Appointment Declaration Form

Patient's Name

First NameLast Name

Email

example@example.com

Phone Number

Age

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please select the doctor that you would like to see.

Doctor Name 1Doctor Name 2Doctor Name 3Doctor Name 4

Preferred Appointment Date & Time

1. In the past 14 days, have you or the the patient traveled or lived in area with a probable/ confirmed case of COVID-19?

YesNo

2. In the past 14 days, have you or the the patient contacted closely with probable/ confirmed case of COVID-19?

YesNo

3. Which of the following symptoms have you or the patient experience in the past 14 days?

4. Which of the following conditions apply to you or the patient?

60 years old or abovewith pre-existing medical conditions (Asthma, Liver Disease, Diabetes, Chronic Lung Disease, etc.)Diagnosed as high-risk pregnancyHealth worker

Medical History*

Please make sure that you answer the questions correctly. If your answers to Question 1 and 2 is "Yes", doctors have the right to arrange your appointment date and time accordingly not to risk other patient's health. In that case, your treatment will be made on our hospital's isolated area.

I declare that the information I have given above is true, correct and complete.

Patient's Signature

Clear