Skip to content
About Us
Procedures
Appointments
Payments
Resources
Patient Forms
Media Center
Contact
Menu
About Us
Procedures
Appointments
Payments
Resources
Patient Forms
Media Center
Contact
Schedule your appointment
Patient COVID-19 Questionnaire Form
"
*
" indicates required fields
Basic Details
Patient Name
*
First
Last
Today's Date
*
MM slash DD slash YYYY
Do you have any cold/flu like symptoms?
*
Yes
No
Do you have a fever?
*
Yes
No
Do you have a cough?
*
Yes
No
Do you have a sore throat?
*
Yes
No
Have you had loss of taste?
*
Yes
No
Have you had diarrhea within the last fourteen days?
*
Yes
No
Have you had exposure to any positive case of COVID-19?
*
Yes
No
Have you worked in an environment with person(s) having tested positive for COVID-19?
*
Yes
No
Terms & Conditions
I certify that I have read and understand the above information. To the best knowledge, the above questions have been accurately answered. I withholding information can be dangerous to the health of the community at large.
Signature
*
12/26/2024
