Full name
*
Email Address
Are you experiencing any of the following symptoms: fever, new or worsening cough, shortness of breath, sore throat, or vomiting/diarrhea?
*
Yes
No
Do you feel feverish?
*
Yes
No
If you answer "yes" to any of the symptoms above,
or if your temperature is 100.4 degrees or higher, please do not come to the office. Self-isolate at home & contact your primary care physician's office for direction.
Have you had close contact in the last 14 days with an individual diagnosed with COVID-19?
*
Yes
No
Have you engaged in any travel in the last 14 days involving areas with active Covid-19 outbreaks?
*
Yes
No
Have you been directed or told by the local health department or your healthcare provider to self-isolate or self-quarantine?
*
Yes
No
If you answer yes to either of these questions,
please do not come to the office. Self-quarantine at home for 14 days.
Any notes - other information to know?
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