COVID-19 Questionnaire
RequiredRequired Question(s)
Required
Please enter the information indicated below.

First Name:
Last Name:
Cell Phone:


IN THE PAST 3 WEEKS, HAVE YOU HAD:
 
Required

A temperature above 99 degrees F?

YES
NO
Required

Cough/sore throat?

YES
NO
Required

Runny nose?

YES
NO
Required

Shortness of breath?

YES
NO
Required

New loss/change of taste or smell?

YES
NO
Required

Fatigue, body aches?

YES
NO
Required

New onset of diarrhea?

YES
NO
Required
In the past 14 days, do you have reason to believe you were exposed to someone with COVID-19?
YES
NO

If you answered YES to any of the above questions, we regret that we are unable to see you at this time. 
Please submit the questionnaire and we will contact you to reschedule when appropriate. Thank you for understanding.

CLICK FINISH TO SUBMIT.