COVID-19 Questionnaire

Important - Please Read
The safety of our employees, clients, families and visitors remain a priority at Zacharia Brown PC. At this time, only ZB employees and clients/visitors with scheduled appointments, are permitted at our offices. In accordance with CDC guidelines and to prevent the spread of COVID-19 and reduce the potential risk of exposure to our employees and visitors, we are conducting a simple screening questionnaire. Your participation is important to help us take measures to protect you and everyone in our offices. Thank you for your time.
Name*
First Last
Zacharia Brown Office Location*
Date of Appointment*
MM slash DD slash YYYY
By signing this document, I expressly agree to the following:
- I have not been diagnosed with COVID-19 in the past 14 days.
- I have not knowingly been exposed to anyone with COVID-19 in the past 14 days.
- I am not experiencing any of the following cold or flu-like symptoms as a new pattern in the last 14 days: Fatigue, Shortness of Breath, Fever, Chills, Cough, Sore Throat, Congestion, or Loss of Taste or Smell.
Please review and answer the following Appointment Pre-Screening Question:
Have you been fully vaccinated for COVID-19?*
“Fully vaccinated” means that if you received a two shot vaccine (i.e. Pfizer or Moderna), you are fully vaccinated two weeks after your second dose; or if you received a one shot vaccine (J&J), you are fully vaccinated two weeks after your single shot.
- Yes
- No
If your answer is YES, you do not need to wear a face mask in our offices.

If your answer is NO, a face covering is required in our offices for any person who is not fully vaccinated as described above.
Signature*
Any questions should be directed to our receptionists. For McMurray and Wexford appointments, called 724-942-6200 and for McKeesport appointments, called 412-751-5670.

By submitting this form, you are certifying that your responses to these questions are truthful to the best of your ability.

COVID-19 Questionnaire

Important - Please Read