ADA screening form
For all of our safety, please fill this out 24 hours prior to each appointment (until further notice). Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the severe COVID-19 signs.
My appointment date
My appointment location
In the past 14 days, I have experienced...
Fever 100°F +
Unexplained body aches or pain
Shortness of breath or difficulty breathing
Chills with or without body aches
Recent loss of sense of smell or taste
Been in contact with any confirmed Covid positive patient
Over the age of 60
Any heart, lung or kidney disease, diabetes or auto-immune disorder
Travel in the last 14 days to any regions affected by COVID-19
Should be Empty: