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COVID-19 Pre-Appointment Questions

To better protect our patients and our staff, all patients are required to sign this form 48 hrs. prior to the scheduled appointment time to certify that you are COVID-19 asymptomatic. If you are currently experiencing any of the symptoms below or you answered "YES", then delay elective treatment for 5 days, then re-evaluate.

PATIENT NAME:

TODAY'S DATE:

PLEASE ANSWER YES OR NO TO THE FOLLOWING

YESNO

1. Do you or have you had any flu-like symptoms in the last 5 days?

Cough
Shortness of Breath
Or at least two of these symptoms:

Fever
Chills
Repeated Shaking
Fatigue
Muscle aches
Vomiting
Headache
Sore throat
New loss of taste or smell
Malaise
Nausea
Diarrhea

2. Are you awaiting results of a lab test for COVID-19?

3. Have you tested positive for COVID-19? When?

4. Have you or a family member previously been taken to self-isolate or self-quarantine in the past 5 days?

5. Have you had close contact to an individual diagnosed with COVID-19 infection in the past 5 days?

6. Have you traveled in the past 5 days to a region with high rates of COVID-19 disease activily?

If yes to any of the above question, delay elective treatment for 5 days, then re-evaluate. Additionally, there will be a mandatory charge of $20 (not covered by insurance) per appointment to cover the cost of Personal Protective Equipment.

Patient's Signature Date

Doctor's Signature Date

Please fill out completely as possible. When submitting online, please type Patient's Name in the signature field above. Submission of this form is same as signing this form.