Please complete prior to appointment.
COVID-19 PATIENT SCREENING
Please check if you have experienced any of the following within the past 14days
SHORTNESS OF BREATH/DIFFICULTY BREATHING
SORE THROAT/TIGHTENING OF CHEST
LOSS OF TASTE
LOSS OF SMELL
Have you had contact with any person who has tested positive for COVID-19 within the past 14 days?
Have you traveled outside the United States within the past 12 weeks?
A parent or guardian must sign if the patient is under 18 years of age.
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