COVID-19 Screening Questionnaire

You must complete this screening questionnaire before each appointment

Please correct the errors described below.

Client Information

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 14 days?

If you answered YES to any COVID symptom questions please DO NOT enter the building; instead, call our office at 901-747-2229 to reschedule your appointment. Please contact your primary care physician for further guidance.
If you answered NO to all, proceed to the next question.

Contact History

If you answered yes, please contact our office at 901-747-2229 and reschedule your appointment.

If you answered yes, please contact our office at 901-747-2229 and reschedule your appointment.

REMINDER: Only patients with appointments are allowed clinic entry. NO Patient Partners or Visitors are allowed clinic entry at this time. Anyone entering the building and clinic is required to wear a facemask. Please remember to social distance and hand wash or hand sanitize frequently when visiting our office.

Fertility Associates of Memphis is committed to helping slow the spread of COVID-19 and is following all recommendations provided by local, state, and national authorities.
Thank you for your support!

Your information will be encrypted.

Loading...