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? *
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:
Your relationship with the patient *
Who do you have an appointment with:
Clear selection
What time is your appointment:
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