• COVID19 Self Assessment Questionnaire

    This questionnaire must be completed prior to your scheduled appointment time.
  • 1. Are you experiencing any of the following:

    • Severe difficulty breathing (e.g. struggling to breathe or speaking in single words)
    • Severe chest pain
    • High fever
    • Chills
    • Sore throat
    • Fatigue
    • Headache
    • Loss of taste or smell
    • Congestion or runny nose
    • Nausea, vomitting or diarrhea
  • Should be Empty:
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