Sign-In Sheet for all Patients
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Name of Patient (First, Last)
Is your child here today with cough, fever, or shortness of breath?
Have you traveled anywhere either internationally or domestically within the last 2 weeks?
If yes specify location(s) of travel
Have you been in contact with anyone diagnosed with or under suspicion of COVID-19 or commonly known as the Coronavirus?
Any changes to your insurance:
Only a new insurance card
No insurance for this visit
Your relationship with the patient
Self (if you are 18+ for this visit)
Other (Please explain to the receptionist)
Who do you have an appointment with:
Dr Laritssa Cobian
Dr Marcela Jativa
Andrea VanDam PA-C
What time is your appointment:
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