Sign-In Sheet for all Patients
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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