Receiving Medical Treatment During the Covid19 Pandemic Questionnaire
RequiredRequired Question(s)
Dear Patient:
You have made an appointment with our office to be treated at this time or seen for a follow-up appointment. Please be advised of the following:

 While our office complies with State Health Department and the Centers for Disease Control and Prevention infection control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees.

 Our staff are symptom-free and to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge.

In order to reduce the risk of spreading COVID-19, we will be asking you several "screening" questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.
Required 1.

Enter initials for your first and last name (i.e. Sue Smith = S. S.) 


50 characters left.
Required 2.
What is your Date of Birth (MM/DD/YY)


50 characters left.
Required 3.
What is the date of scheduled appointment?


50 characters left.
Required 4.

 Have you had a fever (body temp over 100`) in the last 14 days?  

Required 5.

Have you taken any medication to reduce a fever in the last 24 hours? 

Required 6.
Are you experiencing any New Onsets listed below?
Difficulty Breathing
Shortness of Breath
Muscle Pain
Upset Stomach
Extreme Fatique
New Loss of Smell or Taste in the last 14 days
None of the Above
Required 7.

Have you had exposure to someone with COVID19 or someone suspected with COVID-19 in the last 14 days? 

  • Comment:

  • 500 characters left.
Required 8.
Have you traveled in the United States in the last 14 days?
Required 9.

Have you traveled internationally in the last 14 days?  

Required 10.

Have you been tested for COVID19?  

Kuy Plastic Surgery - Patient Protocols During COVID19 Pandemic:
While we are pleased to resume many of our treatments and services on Monday May 4th,
we need to follow strict guidelines to ensure patient and staff safety and well-being during this period.
Prior to your Visit:
  • You must complete our emailed COVID-19 pre-screening survey 3-5 days prior to your scheduled appointment.
  • Please minimize your exposure to others per Ohio advisements.
  • If recent exposure to COVID-19, please call us to reschedule for a later date.
  • Report fever, cold symptoms, cough, headache, or chills to our office.
  • "New Patients" - please complete your Patient Portal prior to arriving at the office.  If you have difficulties please call the office 844.794.7763 and ask for Meagan.
Day of Appointment:
  • Please wear a face mask to office. Expect that all of our staff will be masked, as per local recommendations.
  • NO Accompanying VISITORS will be allowed to enter office with you during this pandemic period unless patient scheduled is a minor or needs assistance.
  • You will be greeted at the door for a temperature check, quick review of COVID-19 survey, and hand disinfection.  We will room you promptly.
  • Please DO NOT arrive any earlier than your scheduled appointment time.
  • Everyone will maintain social distancing within the office.
Visit Options:
  • We are also offering Telehealth visits for consultations or follow-up care.
Know that we are instituting many enhanced cleaning and disinfection measures in the office during this period to ensure that you have a positive, safe experience.
We appreciate the trust that you have placed in us to care for you at this time
We look forward to welcoming you soon.
If your health exposure status changes prior to your appointment, CALL US to postpone!   844.794.7763

Dr. Kuy will review your answers, should he have any questions or concerns he will contact you directly.