COVID-19 PRE-VISIT SCREENING SURVEY

Dopps Chiropractic has been able to continue to serve our community with necessary chiropractic care. As such, we must do everything possible to mitigate risk to our staff and other members of the community so it is vitally important to you complete this form accurate prior to each visit.

Covid-19 Health Declaration

How are you feeling today?

Have you been exposed to COVID-19 or do you believe that you have? □Yes □No Please check any of the following symptoms you(or other members of your family that also have an appointment) are expressing
Have you traveled to or from a high-risk geographic area in the past 14 days? Cruise Ship, River Cruise or Traveled Internationally

Your Signature

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