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COVID-19 Informed
Consent Form
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I understand the COVID-19 virus has a long incubation period during which carriers of the virus are asymptomatic. Our determination to service clients is based on present health conditions. *
No
Yes
Have you had a fever of 100F or higher in the last 24 hours? *
Yes
No
Do you now, or have had recently, any respiratory or flu symptoms, sore throat, runny nose, shortness of breath? *
Yes
No
Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus symptoms? *
Yes
No
Have you been tested for COVID-19? *
Yes
No
If yes, what were your results?
Positive
Negative
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