Patient Advisory and Acknowledgment

Receiving Medical Treatment During the COVID-19 Pandemic

You have come to our office today for a routine medical evaluation and/or treatment that will be done during the COVID-19 pandemic. Please be advised of the following:

While our office complies with the MD 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 have been infected, with or without their knowledge.

In order to reduce the risk of spreading COVID-19, we are asking you to complete the following “screening” questions. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.