COVID-19 Exposure Agreement Form

A signed agreement in which the patient discloses recent symptoms, risk contacts, and travel history to protect both patient and practice before an in-person visit.

Use this template

Full Name

Nombre

Apellido

Email

Phone Number

Do you have any of the following symptoms?:

Fever Cough Shortness of breath Loss of taste or smell

Have you been in contact with anyone in the last 14 days who is experiencing these symptoms?

Yes No

Have you been in contact with anyone who has since tested positive for Covid-19?

Yes No

Have you travelled outside California in the last 1-2 months? Where did you go?

I hereby acknowledge the above symptoms and confirm that I, as well as all the members of my household, have not experienced any listed symptoms within the last 30 days.

Nombre

Apellido

I confirm that I, as well as all members of my household, have not been diagnosed with COVID-19 within the last 30 days.

Nombre

Apellido

I confirm that I, as well as all members of my household, have not knowingly been exposed to anyone diagnosed with COVID-19 in the last 30 days.

Nombre

Apellido

Please sign below

Name

Nombre

Apellido

Signature

Sign here

COVID-19 Exposure Agreement Form

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