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Available Forms

COVID-19 Screening English
First & Last

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.

Approximate date you were exposed
Please include Name and Location of the Facility so that we may request the test results.
Date quarantine ended

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.

First and Last Name

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

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