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COVID-19 Screening Questions
Have you had a fever in the past 24 hours above 100.4°F? *

Yes No
Do you have, or have recently developed, any of the following symptoms: Cough, Fever, Headache, Loss of Smell, Loss of Taste, Muscle Aches, Shortness of Breath, Sore Throat? *

Yes No
Have you been in contact with anyone in the past 14 days that has symptoms or has been diagnosed with COVID-19? *

Yes No
Have you traveled out of the state in the last 14 days? *

Yes No
Where did you travel? *
Patient Information
Have you been or are you currently a patient of BergerHenry ENT? *

Yes No
Name *

First Name Last Name
Cell Phone *

Area Code Phone Number
Cell Phone Provider *
Other Phone

Area Code Phone Number
Email *
example@example.com
Preferred Method of Contact
Address

Street Address

Street Address Line 2
City
State
Zip / Post Code
Birthdate

Month Day Year
Date
Insurance Provider
Insurance ID
Pharmacy Name (if applicable)
Pharmacy Phone

Area Code Phone Number
Family Doctor
Reason for Visit/Symptoms
Have you had any studies done for this issue?

Yes No
What type of study did you have and where was it performed?
Would you prefer to be seen at a specific BergerHenry ENT office location?
Would you prefer to be seen by a specific BergerHenry ENT specialist?
How Did You Hear About Us?
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