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.
Email *
Patient(s) name(s) *
Do you or your child(ren) have a fever? *
Are you or your child(ren) having shortness of breath or difficulty breathing? *
Do you or your child(ren) have a cough? *
Do you or your child(ren) have any other Flu like symptoms such as, upset stomach, headache, or fatigue? *
Have you or your child(ren) experienced recent loss of taste or smell? *
Are you or your child(ren) in contact with any confirmed Covid-19 positive patients? *
Do you or your child(ren) have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders? *
Have you or your child(ren) traveled in the past 14 days? *
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy