COVID-19 Pre-Appointment Questionnaire

Please ask yourselves the following questions. If you can answer any of the following questions with a "Yes", we will need to reschedule your appointment. Additionally, I recommend that you contact a medical professional to seek further assistance. 

Have you come in to close contact with someone who has been diagnosed with the coronavirus in the past 14 days?   Yes  No

Have you traveled out of the state or country in the past 14 days?  Yes     No

Do you have any of these symptoms:

• Fever or Chills                           
• Cough                                      
• Difficulty breathing               
• Shortness of Breath                 
• Body Aches                                 
• Headaches                                     
• New loss of taste or smell
• Sore throat

​Yes    No
Yes    No
Yes    No
Yes    No
Yes    No
Yes    No
Yes    No
Yes    No
Yes    No