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.
Have you experienced any of the following symptoms in the past 14 days?
Please complete this questionnaire again if any of your answers change before your appointment.
If you have responded yes to any of the above questions, other than regarding your vaccine status, please contact our office by telephone to discuss the appropriate next steps.
Your information will be encrypted.
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