PATIENT INTAKE FORMCOVID-19 Guidelines DOLCE AESTHETICS, INC PATIENT INTAKE FORM Date Patient Name Phone Number Email Address Have you had a cough? Yes/No Yes No Patient Initials Have you had a fever? Yes/No Yes No Patient Initials Have you been sick in the past 14 days? Yes/No Yes No Patient Initials Have you been around anyone exhibiting these symptons within the past 14 days? Yes/No Yes No Patient Initials Are you living with anyone who is sick or quarantined? Yes/No Yes No Patient Initials Patient Temperature Please Type Full Name SEND MESSAGE
