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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.
  • Date Format: 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:

  • “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.
  • 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.

  • 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.

Request an Appointment

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