COVID-19 Protocol & Questionnaire

The office of Dr. Scott A. Gradwell

** IF YOU HAVE ALREADY COMPLETED THIS FORM FOR YOUR UPCOMING APPOINTMENT, WE HAVE RECEIVED IT AND YOU DO NOT NEED TO FILL IT OUT AGAIN **

COVID-19 Office Instructions &

Pre Screening Questionnaire

In order to ensure the safety of all patients and office staff, the following protocol is in effect:

You must fill out the below Covid-19 pre-screening questionnaire prior to your appointment.
You must wear a mask while in our office.
If you must be accompanied to your appointment, please limit it to one person.
Upon arrival, your temperature will be taken and you will be asked the pre-screening questions briefly once again.
When entering the waiting room if you see more than 3 people sitting there, please step back into the hallway and give our office a call and let us know you are out there and we will instruct you when to come into the office when there are fewer people sitting there.

By confirming here you understand our new office protocols *

I agree

Name *

First Name Last Name

Email *

example@example.com

Today's Date *

Appointment Date *

Does the patient have a fever or felt hot or feverish in the past 14 days? *

Yes No

Has the patient experienced shortness of breath or had trouble breathing? *

Yes No

Has the patient had a dry cough, sore throat and/or runny nose? *

Yes No

Has the patient recently lost or had a reduction in your taste or sense of smell? *

Yes No

Has the patient been in contact with any confirmed positive COVID-19 patients within the last 2 weeks? *

Yes No

Has the patient tested positive for COVID-19? *

Yes No

If yes, when? Explain

Has the patient or any family members been tested for COVID-19 and waiting for results? *

Yes No

If yes, when? Explain

If you answered yes to any of the above questions please call the office to reschedule your appointment.

Patients who are well but have a sick family member at home with COVID-19 should consider postponing elective treatment

Thank you for your understanding.

Together we are confident that we will be able to get through this difficult time.