Healthcare Health Confirmation Form

HEALTHCARE HEALTH CONFIRMATION FORM

Purpose: This form documents current health status and recent exposure history required to proceed with scheduled clinical services. The information provided will be used to assess infection control precautions and to determine whether services should proceed, be modified, or be deferred. By completing and signing this form, the undersigned attests that the answers are true and complete to the best of their knowledge.

Appointment & Facility

Facility/Provider Name:

Appointment Date:   Appointment Time:   Purpose of Visit:

Patient Information

Insurance Information

Medical History (Relevant)

Current Health & Exposure Screening

Please check all that apply:

Fever (measured or subjective)    New or worsening cough

Shortness of breath or difficulty breathing    Sore throat

New loss of taste or smell    Nausea, vomiting, or diarrhea

None of the above symptoms

Current measured temperature (°F):

I have had close contact with someone confirmed or suspected to have a communicable infectious disease within the past 14 days.

I tested positive for a communicable infectious disease within the past 14 days.   If yes, date of positive test:

I have travelled outside the local area or to a high-risk region within the past 14 days.   If yes, state/country and dates:

Vaccination status for relevant infectious disease (if applicable):    Vaccinated    Not vaccinated   Vaccine type / last dose date:

Acknowledgment, Authorization & Certification

I certify under penalty of law that the information on this form is complete and accurate to the best of my knowledge. I understand that providing false information may result in postponement or denial of services and may have legal consequences. I authorize the facility and its staff to use and disclose the health information on this form as necessary for treatment, infection control, and billing purposes. I acknowledge that I may be asked to update this information if my health status changes prior to my appointment.

I understand the facility may require additional screening, testing, or personal protective measures prior to providing services. I acknowledge my right to refuse services, but I understand refusal may result in cancellation of scheduled care. I agree to notify the facility if I develop symptoms or learn of an exposure after signing this form and prior to my visit.

Privacy Notice Acknowledgment: I acknowledge that I have been provided with or offered the facility's privacy practices that describe how my protected health information may be used and disclosed and how I may obtain access to this information. I consent to the use and disclosure of my health information for the purposes stated above.

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