Frederick (English) UPDATED In Person Client Appointment Form

Name

First Name

Last Name

What is the Date and Time of your Appt?

:

1. Have you received your final COVID shot and has it been at least 14 days since that shot?

Yes No

2. Are you having any COVID-19 symptoms such as loss of taste or smell, fever over 100 degrees, coughing, shortness of breath, unexplained gastrointestinal problems or chills?

Yes No

3. Have you been exposed within the last 14 days to anyone who tested positive for COVID-19?

Yes No

4. Have you traveled outside the United States in the last 14 days?

Yes No

To what country did you travel?

What was the date of your return to the United States: