Office Visitor Form

Office Visitor Form
Name
First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Visit Date
MonthDayYear
Date
COVID-19 Symptoms:
- Fever of chills (fever = 100.4°F/38°C or above)
- Cough
- Shortness of breath or difficulty breathing
- Fatigue
- Muscle or body aches
- Headache
- New loss of taste or smell
- Sore throat
- Congestion or runny nose
- Nausea or vomiting
- Diarrhea
To visit the office you must not be experiencing any of the symptoms listed above
I am not experiencing any of the COVID-19 symptoms listed above.
You must meet at least one of the following criteria to visit the office. Please select the one(s) applicable to you.
I am fully vaccinated. (people are considered fully vaccinated for COVID-19 two or more weeks after they have received the second dose in a 2-dose series or two or more weeks after they have received a single-dose vaccine)I have obtained a negative COVID-19 test within 72-hours of your visit.
Signature
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