1. Active TB,
2. Persistent Cough for longer than 3 wks
3. Cough that produces blood?
If you answered yes to any of the above, please stop & return this form to the front desk.
Note: We encourage you to discuss any and all relevant patient health issues prior to treatment.
I certify that I have given answers to the above questions to the best of my knowledge. I will not hold Dr. Sheikh or any of his staff responsible for any action they take or do not take because of errors or omissions that I may have made in completion of this form.