COVID-19 Infectious Disease Screening

Please correct the errors described below.

The purpose of this screening questionnaire is to screen for potentially contagious COVID-19 and to protect patients as well as staff.

All patients must be wearing a mask when entering the clinical area/office.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.