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Bloom Ob/Gyn Covid-19 Questionnaire
Please complete this form 24-48 hours prior to your appointment.
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Email
*
Your email
Please enter your Last name
*
Your answer
Please enter your DOB
*
Your answer
Please enter the date of your appointment
*
MM
/
DD
/
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Have experienced any of the following symptoms in the past 48 hours: fever or chills, coughing, congestion or runny nose, sore throat, headaches, or any other symptoms related to Covid-19?
*
Yes
No
Are you currently waiting on the results of a COVID-19 test?
*
Yes
No
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