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Website3.0_Patient Pre-Screening Form
HIPAA
Compliance
1
Name
*
This field is required.
Please enter the name of the patient of record who has an appointment at our office.
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2
Mobile Phone
*
This field is required.
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3
Email
*
This field is required.
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4
Do you have a fever or have you felt hot or feverish in the last 5 days?
*
This field is required.
YES
NO
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5
Have you experienced shortness of breath or had trouble breathing?
*
This field is required.
YES
NO
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6
Do you have a cough unrelated to a pre-existing condition?
*
This field is required.
YES
NO
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7
Do you have a runny nose or nasal congestion unrelated to allergies?
*
This field is required.
YES
NO
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8
Do you have a sore throat?
*
This field is required.
YES
NO
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9
Are you experiencing flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?
*
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YES
NO
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10
Do you have any cold sores?
*
This field is required.
YES
NO
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11
Acknowledgement
By checking the box below, you acknowledge that your answers that you provided are true and accurate to the best of your knowledge, and will notify Dr. Ratliff if any of your answers change in the next two weeks.
I agree to the Acknowledgement above.
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