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Health Declaration
Please fill this form out prior to your appointment for a pre-check in consultation.
First Name
Last Name
Email
My body temperature is lower than 98.6°F/ 37.5°C
Have you traveled outside New York State in the last three weeks?
No
Yes
Check all that apply
I don't have any flu symptoms..sore throat,cough,chills
No one in my house has Covid 19 or symptoms
I've had no contact with anyone who is Covid Positive or exhibiting symptoms
Date
Initials
I confirm that the information given in this form is true
Submit
Thanks for submitting!