Please fill out (ONLY ONE/SERVICE) and submit the following questionnaire before every visit.

If the answer to any of the following questions is yes, please cancel your upcoming appointment and reschedule for a later date.  
 
Health experts are still learning the details about how this new coronavirus spreads.  Other coronaviruses spread from an infected person to others through;  the air by coughing and sneezing, close personal contact (such as touching or shaking hands), touching an object or surface with the virus on it, then touching your mouth, nose, or eyes.  Please contact Oregon Health Authority for further information regarding the new coronavirus.

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* 1. Please enter your contact information.

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* 2. Have you had 2 OR MORE of the following symptoms in the last 10 days;      *fever over 100.5
  *shortness of breath
  *dry cough
  *fatigue
  *unexplained muscle aches
  *unexplained headache
  *new loss of smell/taste
  *sore throat
  *congestion or runny nose
  *nausea or vomiting
  *diarrhea

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* 3. Have you (or someone you live with) been in contact with anyone that has had the above symptoms, or someone that has tested positive for COVID in the last 10 days?

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* 4. Have you traveled to or from an affected geographic area with widespread or sustained community transmission in the last 14 days?

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* 5. Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be at your gym, grocery store, or favorite restaurant.

Although we have taken measures to provide social distancing in our practice, due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, Chiropractor, Chiropractic staff and sometimes other patients at all times.

Although exposure is unlikely, do you accept the risk and consent to treatment?

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* 6. I understand and agree with the above consent.  

(Type name for Electronic signature below)

0 of 6 answered
 

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