EmailMeForm
COVID-19 Client Waiver
In an effort to reduce the risk of COVID-19 exposure to Coldwater Animal Hospital employees, anyone entering the building must complete the following screening questions:
Name
*
First
Last
Phone
*
###
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###
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Patient Name
*
Self-Declaration
Visitors answering yes to any of the following questions will not be permitted access to Coldwater Animal Hospital's facility.
Have you traveled outside of New York State or been in close contact with anyone who has traveled outside of NYS within the last 14 days?
*
YES
NO
Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?
*
YES
NO
Have you experienced any cold or flu-like symptoms in the last 14 days (fever, cough, shortness of breath, or other respiratory problem)?
*
YES
NO
Signature
*
Clear