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.