PRIOR TO THE START OF MY VISIT, I CONFIRM THAT:
I have not been diagnosed with or cared for someone diagnosed with COVID-19 in the past 14 days.
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Confirm
I have not shown symptoms of COVID-19 or come in close contact with anyone exhibiting these symptoms in the past two weeks.
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Confirm
I have not traveled outside of my immediate daily routine for the past two weeks.
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Confirm
I do not have a cough, fever, shills, shortness of breath, or loss of taste or smell.
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Confirm
If I begin to show symptoms of COVID-19 within the two weeks, I will contact my audiologist at All About Hearing Inc. (432-689-2220)
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Confirm
I will follow all posted office rules to wear a mask and keep those around me safe
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Confirm
Patient Name:
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First Name
Last Name
Date
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Month
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Day
Year
Date
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