Please fill out the mandated COVID-19 Screening Form below before your next appointment.

Are you a current or new patient?*
Patient Name*
Question 1: Are you immunocompromised and/or live in a highest-risk congregate care setting?*
Question 2: Do you have any of these symptoms? Choose any or all that are new, worsening and not related to other known causes or conditions.*
Question 3: Have you been told (by a doctor, health care provider, public health unit, federal border agent, or other goverment authority) that you should currently be quarantining, isolating or staying at home?*
Question 4: In the last 10 days, have you tested positive for COVID-19 on a laboratory-based PCR test, rapid molecular test, rapid antigen test or other home-based self-testing kit?*
MM slash DD slash YYYY