Please enter a valid phone number.
Street Address Line 2
State / Province
Postal / Zip Code
What meds have you used to manage your nasal symptoms?
(e.g., Flonase, Claritin, Singulair, Mucinex, Afrin)
Primary Care Provider
Symptoms of Concern (please select all that apply)
Loss of Taste/Smell Post-COVID
I understand and agree that any information submitted will be forwarded to our office by email and not via a secure messaging system. This form should not be used to transmit private health information, and we disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form.
Should be Empty: