Wellness Verification Form

This form is to be completed within 30 minutes of the start time of your appointment.

Please read this carefully and let us know if you have any questions.

I am aware of the risk factors (initial)

I have considered CDC special risk factors and special health-care considerations that may apply to me, my child, and family members and have consulted with my family health-care provider if I have questions about engaging in this type of an appointment.

COVID-19 (initial)

I verify that no one in my household or regular contact of mine has had verified or suspected COVID-19 within the past 3 weeks.

Illnesses (initial)

I verify that no one in my household or regular contact of mine is sick, is showing potential symptoms of COVID-19, or has had any of the symptoms below in the last 3 weeks.

Please select any current symptoms if applicable.

Vaccine – I have been vaccinated

Yes
No

Consent

I understand that even with the best of precautions, exposure control has limitations and I understand the risks of engaging with in person treatment at this time.

Your Printed Name*

Name of Minor or Dependent Adult Patient if other than self

Patient Date of Birth*

Today's Date*

Current Time*

:

Signature*

**For the purpose of completing this form digitally, I attest that my typed signature can be used in place of a physical signature

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Phone

This field is for validation purposes and should be left unchanged.