COVID-19 Screening Questionnaire

You must complete this screening questionnaire before each appointment

Please correct the errors described below.

Patient Information

Appointment Information

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

Q1. Immune/Risk status

Q2. Symptom History

Do you have any of the following symptoms that are new, worsening and not related to other known causes or conditions?

Q3. Self Isolating

Q4. Positive COVID-19 test

Please complete this questionnaire again if any of your answers change before your appointment.

NOTE: If you have had any changes to your overall health since your last appointment at our office, please contact the front desk

Remember that mask wearing is recommended when entering the office.

Your information will be encrypted.