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COVID-19 Pre-appointment Screening, Dr. Slotnick
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All office entrants are asked to complete this screening within 24 hours of their office visit.
We kindly request that you help us facilitate social distancing at our cozy office. Please make every effort to leave siblings at home. We will be happy to record discussions or open a video-conference for additional participants.
My visit is for: (Provide PATIENT name: FIRST LAST)
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I will be entering the office as a ___
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Patient
Parent
Companion/ Aide/ Health support
FIRST name of Respondent:
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LAST name of Respondent:
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