Pre-Appointment Declaration Form

Patient's Name

First NameLast Name

Email

example@example.com

Phone Number

Format: (000) 000-0000.

Age

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please select the doctor that you would like to see.

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?

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

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?

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