Dear Customer,

Please, take a moment to answer pre-appointment patient screening questions, to assess potential COVID-19 symptoms or exposure before entering the office or clinic.
Your information will be kept confidential and will be reviewed by a practice clinician. If you answered “yes” to any of the questions, we will provide guidance regarding any adjustments to your scheduled appointment.

Thank you for your cooperation.

• Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at/greater than 100 degrees Fahrenheit?

• Have you or anyone in your household been tested for COVID-19?

• Have you or anyone in your household visited or received treatment in a hospital, nursing home, tong-term care, or other health care facility in the past 30 days?

• Have you or anyone in your household traveled in the U.S. in the past 21 days?

• Have you or anyone in your household traveled on a cruise ship in the last 21 days?

• Are you or anyone in your household a health care provider or emergency responder?

• Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19?

• Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?

• To the best of your knowledge, have you been in close proximity to any individual who tested positive for COVID-19?