Have you seen any other providers for this condition?
Have you had any of the following conditions in the PAST?
Do you or any of your immediate family have any of the following?
To help minimize the risk to myself and other patients, please certify below that the following statements are true:
In the past ten days, I have not come into contact with anyone who has tested positive for COVID-19 (Corona Virus).
In the past week, I have not tested positive for COVID-19 (Corona Virus).
In the past two days I have not experienced any of the following symptoms:
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