Coronavirus

Answers to the prescreening questions below is required prior to arriving to your appointment.
Patient Name*
Phone Number

Area CodePhone Number
Phone Number Type

MobileHome LandlineWork
Email*
Have you or your child been in close contact (less than 6 ft) with a confirmed case of coronavirus (Covid-19)?*

YesNo
Have you or your child traveled within the past 14 days?*

YesNo
If yes to the question above, please answer below:

Travelled OUTSIDE the US by air or cruise ship within the past 14 daysTravelled WITHIN the US by air, bus or train within the last 14 days
Are you or your child currently experiencing flu-like symptoms (cough, difficulty breathing, shortness of breath, fever)*

YesNo
Please specify details of the symptoms
By submitting I hereby confirm that the information I have given above is true.
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