In order to minimize risk and protect our patients and staff from contracting COVID-19 we ask that you complete these questions truthfully and to the best of your knowledge prior to your in office appointment.




Location (required)

Have you experienced any of the following symptoms in the last 14 days? Please check applicable.
Fever greater than 100.4Body AchesShortness of BreathRespiratory Distress

Have you been in close contact with anyone who has traveled?YesNo

Have you had close contact with or cared for someone diagnosed with COVID-19?
YesNo

Have you worked or volunteered in a hospital, emergency room, clinic, medical office, long-term care facility or nursing home, ambulance service, first responder services, or any health care setting or taken care of patients as a student or part of your work?
YesNo

Do you live in a long term care facility or nursing home?
YesNo

Have you taken an airplane flight in the past two weeks?
YesNo

If you answered yes to the above question, did you quarantine yourself for at least 2 weeks upon your return?
YesNo

By checking the following box I attest that the given answers are true and I understand that if any of the answers given are false, I am putting the office personnel and others entering the building at risk for contracting COVID-19. I also understand that while in the office I may be exposed to the virus by no responsibility of the Practice.