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