COVID-19 Screening Questionnaire

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This COVID-19 screening questionnaire must be completed before each visit to the office, on the day of the appointment.

Appointment Information

You must complete this COVID-19 screening questionnaire before each visit to our office on the day of your visit. Please confirm today's date and the date of your appointment.

Symptom History

Have you experienced any of the following symptoms in the past week?

Have you experienced any of the following symptoms in the last 74 hours?

Contact History

Thank you for helping us keep all our staff and patients safe by taking the time to complete this questionnaire. If you answered yes to any of the questions stay home or in your car until you are given further direction by a staff member, someone will call you when we receive this form or you can contact us at (916) 536-6030

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