Checklist for your visit at [PRACTICE NAME]

First name

Last name

Bring my mask

If you don't have one, one will be available for purchase

Send a copy of my insurance card

Upload at the bottom of this form or email to [PRACTICE EMAIL]

Send a copy of my driver's license

Upload at the bottom of this form or email to [PRACTICE EMAIL]

I had my phone interview with [PRACTICE NAME]

I completed and signed the acknowledgement form

I consent to having my temperature checked when I arrive for my appointment

I am coming by myself, or, if I am parent to a minor, I am accompanying that patient alone

To maximize social distancing, we are only allowing one patient in the examination room, unless it is a minor, in which case we will allow one parent/guardian

Driver's license and insurance card (both sides)

Add file

Please upload a file

Signature

Date

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