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COVID-19 Acknowledgement and Disclosure Risk Form

Our goal is to provide a safe environment for our clients and staff, and to advance the safety of our local community. This document provides information we ask you to acknowledge and understand regarding the COVID-19 virus.

The COVID-19 virus is a serious and highly contagious disease. The World Health Organization has classified it as a pandemic. You could contract COVID-19 from a variety of sources. Our practice wants to ensure you are aware of risks, and that we follow the safety protocols.

It is important you disclose to this office any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with COVID-19 virus.


Are you fully vaccinated?(Required)
Do you have a fever or above normal temperature?(Required)
Have you experienced shortness of breath or had trouble breathing?(Required)
Do you have a dry cough?(Required)
Do you have a runny nose?(Required)
Have you recently lost or had a reduction in your sense of smell?(Required)
Do you have a sore throat?(Required)
Have you been in contact with someone who has tested positive for COVID-19?(Required)
Have you been tested for COVID-19 and are awaiting results?(Required)
Have you traveled within the past 14 days?(Required)
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.

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