Patient Screening Form
The following questionnaire needs to be submitted within 24 hours of your appointment in order to be submitted.
Patient Name *
Your answer
Do you/they have a fever or have you/they felt hot or feverish recently (14-21 days)? *
Are you/they having shortness of breath or other difficulties breathing? *
Do you/they have a cough or any other flu like symptoms, such as gastrointestinal upset, headache, or fatigue? *
Have you/they experienced loss of taste or smell? *
Are you/they in contact with any confirmed COVID-19 positive patients? *
Have their been any changes to your/their medical history since your last visit? *
If you answered "yes" to any question above please provide more information.
Your answer
Submit
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