Language
English (US)
Spanish (Latin America)
Name
*
First Name
Middle Name
Last Name
Appointment Date
*
-
Month
-
Day
Year
Date
Email
Confirmation Email
example@example.com
Is there any other family members with an appointment the same day?
Yes
No
Please Specify the number
Family Member 1
First Name
Middle Name
Last Name
Family Member 2
First Name
Middle Name
Last Name
Family Member 3
First Name
Middle Name
Last Name
Family Member 4
First Name
Middle Name
Last Name
Family Member 5
First Name
Middle Name
Last Name
Family Member 6
First Name
Middle Name
Last Name
Family Member 7
First Name
Middle Name
Last Name
Did you (the patient) had close contact with a confirmed case of COVID-19?
*
Yes
No
Has the patient been tested positive for COVID recently?
*
Yes
No
Are you still under quarantine?
*
Yes
No
Have you travelled outside of the country in the past 14 day?
*
Yes
No
Do you currently have any of the following symptoms, or have had any symptoms within the last 14 days?
*
NONE
Fever
New Onset Of Cough
Worsening Chronic Cough
Shortness Of Breath
Difficulty Breathing
Sore Throat
Difficulty Swallowing
Decrease Or Loss Of Sense Of Taste
Decrease Or Loss Of Sense Of Smell
Chills
Headaches
Unexplained Fatigue
Muscle Aches
Nausea / Vomiting
Diarrhea
Abdominal Pain
Pink Eye
Runny Nose
Nasal Congestion
If you experience any of the above symptoms prior to your scheduled appointment and after this form is submitted, I agree to notify the office as soon as possible. I understand that my appointment will be rescheduled as a result.
*
I Understand
I acknowledge that a screening form must be filled out for each appointment scheduled until further notice.
*
I Understand
Any Comments:-
I, myself or the legal guardian of the minor named above, acknowledge that the information I have provided is true to the best of my knowledge. Please type your name and provide with your signature.
*
Signature
I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office – in just the same way as a pen-and-paper signature.
Clear
Date
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Print
Save
Submit
Should be Empty: