Visitor COVID Questionnaire

Help us prevent the spread of this harmful virus

The virus that causes COVID-19 can be spread to others by infected persons who have few or no symptoms, especially between unvaccinated individuals who are physically near each other in enclosed spaces. Persons who have the COVID 19 virus, even if they show no symptoms, may spread the virus to others who may become seriously ill. Because this threat is hidden, the virus highly communicable and the consequences of illness potentially severe, all visitors are required to complete this questionnaire and agree to follow the directions incorporated herein.

The CDC issued revised guidance for fully vaccinated individuals on May 13, 2021 allowing for resumption of normal activities without wearing a mask or maintaining 6 feet distance, both indoors and out, except where required by federal, state, local, tribal, or territorial laws, rules, and regulations, including local business and workplace guidance.

The CDC issued interim health guidance on Tuesday July 27, 2021 in response to data driven evidence related to the Delta Variant recommending fully vaccinated people wear properly fitted masks in public indoor settings in areas of substantial or high transmission rates. You may be subject to mask requirements on the date of your office visit pursuant to this guidance.


I am fully vaccinated. (To be considered fully vaccinated, you must be two weeks beyond receipt of the second dose of the PFIZER or MODERNA vaccine or the single dose Johnson & Johnson vaccine.

If you are not fully vaccinated or do not wish to disclose your vaccination status, you must (i) wear a mask that covers your nose and mouth, (ii) maintain 6 feet of separation from others while navigating all common areas within our space and (iii) answer the following questions on the date of your visit. Should you answer “yes” to any of the questions below, please reschedule your office visit.

Have you experienced symptoms such as fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting or diarrhea in the past 48 hours?

Have you been in close contact in the last 14 days with anyone who is known by you to have laboratory-confirmed COVID-19 or anyone who has any symptoms consistent with COVID-19? Close contact is defined as being within 6 feet of an infected/symptomatic individual for a cumulative total of 15 minutes within a 24-hour period.

Are you currently awaiting the results of a COVID-19 test?

Have you traveled internationally in the past 10 days and have not received a negative COVID-19 test result administered 3-5 days following your return?


I affirm that my responses to the questions above are true and correct and that I will comply with the requirements set forth above.

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