Covid-19 Screening

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Covid-19 Screening

Please answer each question prior to submitting. If you answer yes to any question below, please call the office prior to your appointment.

Patient(s) name(s) *

Do you or your child(ren) have a fever? *

Yes

Are you or your child(ren) having shortness of breath or difficulty breathing? *

Yes

Do you or your child(ren) have a cough? *

Yes

Do you or your child(ren) have any other Flu like symptoms such as, upset stomach, headache, or fatigue? *

Yes

Have you or your child(ren) experienced recent loss of taste or smell? *

Yes

Are you or your child(ren) in contact with any confirmed Covid-19 positive patients? *

Yes

Do you or your child(ren) have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders? *

Yes

Have you or your child(ren) traveled in the past 14 days? *

Yes

Other:

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