Pre-screening Form
Patient Name
*
First Name
Last Name
Appointment Date
-
Month
-
Day
Year
Date
Phone Number - preferably a cell number
*
-
Area Code
Phone Number
Email
example@example.com
If you answered YES to this question then please submit this form and call our office (902 835-1031). Please answer YES or NO to the following question. Please note: If there will be an attendant (maximum 1 person) with the patient these answers will apply to both of you.
*
Rows
YES
NO
1) Is anyone in your household experiencing cold or flu like symptoms?
Explain any YES answers in the box below:
Signature:
*
Signature can be written with your mouse or your finger.
Please advise the office (902 835-1031) if any of these answers change before your appointment time.
Submit
Should be Empty: