Our families, staff, and community mean a great deal to us, and your safety is our top priority! During the COVID -19 pandemic, we have instituted a screening process. Please complete this questionnaire prior to entry into our office.
Your responses will be kept confidential and will be reviewed by a practicing clinician who will provide guidance regarding any adjustments to the patient’s scheduled appointment.
1. Have you or anyone in your household had any of the following symptoms in the last 21 days: (If yes, Please check all the boxes that apply)?
Signature of Patient or Guardian