Per CDC recommendation, the purpose of this form is to ensure proper infection control procedures are taken for any patients who may have or potentially have been in recent contact with the 2019-nCOV (Coronavirus) to prevent infections from spreading during healthcare delivery. Note that the signs and symptoms of the 2019-nCOV overlap with those associated with other viral respiratory tract infections. Given the time of year, common respiratory illnesses, including influenza, are also considered.
In following both CDC recommendations, this questionnaire is designed with your safety in mind. Your answers will be reviewed prior to your appointment and a member of our team will contact you if we recommend rescheduling to a later date. Thank you for your consideration and understanding.