Name *

First Name

Last Name

Phone Number *

(###)

###

####

Do you have a fever or above normal temperature? *

Yes

No

Have you experienced shortness of breath or had trouble breathing? *

Yes

No

Do you have a dry cough? *

Yes

No

Do you have a sore throat? *

Yes

No

Do you have a runny nose? *

Yes

No

Have you recently lost or had a reduction in your sense of smell? *

Yes

No

Have you been in contact with someone who has tested positive for COVID-19? *

Yes

No

Have you tested positive for COVID-19? *

Yes

No

Have you been tested for COVID-19 and are awaiting results?

Yes

No

Have you traveled outside the United States by air or cruise ship in the past 14 days? *

Yes

No

Have you traveled within the United States by air, bus or train within the past 14 days? *

Yes

No

I affirm that my answers are correct to the best of my knowledge. *

For the safety of our patients and staff, this form agreement is required.

Yes

No