COVID-19 Screening Questionnaire

You must complete this screening questionnaire before each appointment

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Patient Information

Appointment Information

You must complete this COVID-19 screening questionnaire before each visit to our office. Please confirm today's date and the date of your appointment.

Symptom History

Have you experienced any of the following symptoms in the past 14 days?

Contact History

Please complete this questionnaire again if any of your answers change before your appointment.

I agree to notify the practice if within 14 days I become ill with COVID-19 symptoms or test positive for COVID-19. I understand that if I do not provide the whole truth when completing this form or I am misleading in any way, I will be dismissed from the practice.

To the best of our knowledge, Chevy Chase Foot & Ankle LLC staff are symptom-free at the time of your visit. However, since we are a place of healthcare services, other persons (including other patients) could be infected, with or without their/our knowledge.

While our office complies with Federal, 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 about your health and safety.

I hereby acknowledge and understand that there may be an increased risk that COVID-19 may be transmitted in any place of public accommodation, which includes my physician’s office. I have been informed by my physician of their desire to protect their patients, staff, and the community at large.

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