- Patient Advisory Treatment Acknowledgement During the COVID-19 Pandemic
While our office complies with State Health Department and the Centers for Disease Control and Prevention infection control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees. Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge. In order to reduce the risk of spreading COVID-19, we have asked you a number of “screening” questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.
To view and acknowledge, please click button below.
- Online Patient Questionnaire
We are asking you to complete new patient questionnaire enabling our clinical and administrative staff to prepare for your first visit and to make your check-in for your appointment quicker and easier. Our questionnaire consists of 5 documents. To complete a document, simply fill out the fields with the requested information. While most of the fields are optional, certain fields, marked by asterisks, must be completed. When you have completed a document please review your entry, click the Submit button to move to the next document. Please don’t use your browser’s Back or Forward buttons. Use of these buttons may ‘undo’/’redo’ your recent actions and may result in errors. Please note that the information you will submit will be encrypted for your protection and goes directly to our office. We appreciate the time that you will spend providing the information helping us prepare for your visit.
Please note that the information you will submit will be encrypted for your protection and goes directly to our office. We appreciate the time that you will spend providing the information helping us prepare for your visit.
Thank you and please call our office (478) 477-2761 or email to firstname.lastname@example.org if you have any questions.
To start, please click the Start button below.Start