Dr. Cavale and Dr. Schorr Patient Questionnaire
COVID 19 Pre-in office Appointment Questionnaire: Please answer all the questions. Call us at 215 953 6804 if you need assistance. Thank you for your cooperation!
Please note, we will check your temperature before you enter the office. If you have an abnormal reading, you will be asked to go back to your car. Please notify our office if you test positive for COVID-19 within 14 days of your appointment. We appreciate your cooperation and taking the time to fill this questionnaire.
Name (First and Last) *
Year of Birth
Date of your appointment with Dr. Cavale or Dr Schorr *
MM
/
DD
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YYYY
Phone Number (best number to reach you) *
Email Address
Have you tested positive for COVID 19? *
Have you been in contact with an individual who had COVID 19? *
Do you have any of the following symptoms? Please check all that apply. If you check any of the first four boxes below, please call our office immediately. *
Required
Please acknowledge that you will wear a mask for the in office appointment. *
Will anyone accompany you to the visit? (Limit 1 and mask is required) Person accompanying you must answer this questionnaire separately if they are not an immediate family member. *
Are you aware that you can send messages, request prescriptions, get blood work scripts on our Portal? We are also on Facebook, check us out for patient well being and health related articles @DECPALLC
Please note, we will check your temperature before you enter the office. If you have an abnormal reading, you will be required to go back to your car. Please notify our office if you test positive for COVID 19 within 14 days of your appointment. We appreciate your cooperation and taking the time to fill this questionnaire. Thank you!
(Don't forget to click on the Submit button. Limit 1 response per patient)
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