M.T. Curry Inc

Patient Name * Date of Birth *

As your child?s Primary Care Provider, their health and safety is important to us. Please answer the following questionnaire honestly. Knowing that you may be at risk will help us to ensure the safety of our other patients and staff. Please be aware that our office is not outfitted with the required equipment to test for or treat the Coronavirus.

1. In the past 14 days has the patient had a fever (temperature of 100.4 or higher) or felt hot or feverish? * 2. Has the patient experienced any of the following symptoms: (check all that apply) * 3. In the past 14 days has the patient experienced any 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. In the past 14 days has the patient been tested for COVID-19? * 5a. If YES, when were they tested? 5b. If YES, where were they tested? 6. Have you or anyone in your household been quarantined due to a suspected case of COVID-19 or exposure to someone with COVID-19? * 6a. If YES, when did they finish quarantine?

I understand that it is in the best interest of the patient for me to provide true and accurate information on this waiver to ensure that M. T. Curry pediatrics staff and patients may take the necessary steps to prevent the spread of COVID-19.

I understand that should the information I provide on this waiver be false and/or the patient has been infected with COVID-19 that it will result in the immediate dismissal of myself/my child from M. T. Curry Pediatrics.

I agree that the above information is true and accurate. * Patient/Guardian 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 unless for the purpose of examination.

Revised May 2021