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Cryobank Covid-19 and Health Screening Form

Family Healthcare of Fairfax, P.C.

WE ASK THAT YOU COMPLETE THE "SCREENING" QUESTIONS BELOW FOR THE SAFETY OF OUR STAFF, OTHER PATIENTS AND YOURSELF, PLEASE BE TRUTHFUL AND CANDID IN YOUR ANSWERS.

IF YOUR ANSWERS TO THE ABOVE QUESTIONS CHANGE BEWEEN NOW AND YOUR OFFICE VISIT, PLEASE NOTIFY US SO THAT WE CAN RESCHEDULE YOUR APPOINTMENT.

WE HAVE INSTITUTED SAFETY MEASURES IN OUR OFFICE CONSISTENT WITH PUBLISHED GUIDELINES BUT A RISK OF VIRAL TRANSMISSION REMAINS. YOUR UPCOMING MEDICAL VISIT TO OUR OFFICE IS VOLUNTARY AND WE REQUEST YOUR WRITTEN CONSENT FOR THE VISIT BY TYPING YOUR NAME AND TODAY'S DATE IN THE BOXES BELOW:

Type your full name
Enter date you have completed and submitted this form.
* Required field