Covid-19 Acknowledgement

Has patients or contractors confirm, through a short set of health questions, that they show no COVID-19 symptoms or exposure risk before their visit to a medical practice.

Use this template

Contractor Name

Nombre

Apellido

By checking the boxes, you confirm that you agree with the following statements:

I have not experienced COVID-19 symptoms in the past 14 days I agree to notify the practice immediately if I develop symptoms

Do you have any of these symptoms? - cough, shortness of breath, high fever, muscle pain, body ache, nausea, loss of taste/smell

Yes No

Within 14 days, have you been in contact with anyone that has COVID-19 symptoms or get infected?

Yes No

Are you living with anyone that is infected or quarantined due to COVID-19?

Yes No

Additional Comments

Your Name

Nombre

Apellido

Date

Your Signature

Sign here

Covid-19 Acknowledgement

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