In order to keep all our patients and staff safe during the recent COVID-19 outbreak we ask you to take a moment to fill out this questionnaire:
In the past 2 weeks have you traveled internationally:
Are you experiencing any of the following symptoms:
Have you been in close contact with anyone who has recently traveled to the above locations or has the symptoms mentioned above?
Have you been in close contact with someone has COVID 19?
Have you been Tested for COVID 19?
Are you currently working in an industry providing critical services that require you to work on location includes: such as grocery, banking childcare,etc.)
COVID-19 (coronavirus) can effect people who have weaker immune systems from things like chemotherapy, HIV/AIDS, organ transplant, being pregnant, or prolonged steroid use. Does any of this apply:
I, undersigned with my digital signature, that I certify all the above information is true to the best of my knowledge and that I have not omitted any pertinent information.