Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone

(###)

###

####

Have you had a fever in the last 14 days? *

Yes

No

In the last 14 days have you been in contact with a confirmed or suspected Covid-19 patient? *

Yes

No

Have you experienced any shortness of breath or cough? *

Yes

No

Have you experienced any flu-like symptoms in the last 14 days? *

Yes

No

I acknowledge a mask and pre-appointment temperature taken by our front desk are required before entering the building for my appointment. *

Yes