COVID-19 Questionnaire for Arriving Patients
This survey is intended for any and all patients arriving at our office. Please respond carefully to each question below. Thank you for helping us keep our patients and staff safe during these uncertain times - Lloyd Takao, MD, Pediatrics
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Patient Name *
Date of Appointment
MM
/
DD
/
YYYY
Have you had any COVID-19 exposures in the past 2 weeks? *
Has anybody in your household had any of fever, chills, or fatigue in the last 72 hours? *
Has the patient or any household members travelled in the past 2 weeks? *
Any questions or concerns?
Submit
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