M.T. Curry Inc

Name * Reason for visit *

Please answer the following questionnaire honestly. Knowing that you may be at risk will help us to ensure the safety of our patients and staff. Please be aware that our office is not outfitted with the required equipment to test for or treat the Coronavirus.

1. Have you had a fever (temperature of 100.4 or higher) or felt hot or feverish in the past 14 days? * 2. Are you experiencing any of the following symptoms: (check all that apply) * 3. Have you experienced any other flu-like symptoms such as upset stomach, headache or fatigue? 4. Have you or anyone in your household come into contact with a confirmed COVID-19 (Coronavirus) positive individual ? * If YES, when? 5. Have you or anyone in your household been quarantined due to a suspected case of COVID-19 or exposure to someone with COVID-19? * If YES, when? I agree that the above information is true and accurate. * Signature * Today's Date *

Masks are REQUIRED for all guests 3 years and older. Please have your mask on prior to entering our offices. Masks SHOULD NOT BE REMOVED at any point.