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Patient Examination Disclosure Form
Please fill the form below
1
Step 1
2
Step 2
Patient Information
Name:
First Name
Last Name
This field is required.Please enter value
This field is required.Please enter value
Date of Birth:
This field is required.Please enter value
Date format is invalid, please check it again
The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
Email id:
This field is required.Please enter value
Please enter valid email address
Mobile No:
This field is required.Please enter value
Invalid phone number.
The value must be less than or equal to 20
Vehical Information
Make,Model,Color:
Make:
Please select value
Toyota
Honda
Model:
Please select value
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Color:
Please select value
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This field is required.Please enter value
Patient Screening
Do you have heart disease, lung disease, kidney disease, diabetes, asthma, or any auto-immune disorders:
Yes
No
This field is required.Please enter value
Do you have a fever or have you felt hot or feverish recently (14-21 days):
Yes
No
This field is required.Please enter value
Have you experienced shortness of breath or had trouble breathing:
Yes
No
This field is required.Please enter value
Do you have a cough:
Yes
No
This field is required.Please enter value
Do you have a runny nose:
Yes
No
This field is required.Please enter value
Do you have a sore throat:
Yes
No
This field is required.Please enter value
Next
Are you experiencing flu-like symptoms, such as gastrointestinal upset, headache, or fatigue:
Yes
No
This field is required.Please enter value
Have you experienced a recent loss of taste or smell:
Yes
No
This field is required.Please enter value
Have you been in contact with anyone who has tested positive for COVID-19:
Yes
No
This field is required.Please enter value
Have you traveled anywhere by air, bus, or train within the past 14 days:
Yes
No
This field is required.Please enter value
Have you been tested for COVID-19:
Yes
No
This field is required.Please enter value
Comments:
This field is required.Please enter value
Signature:
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