COVID-19 Supplemental Health Questionnaire

COVID-19 SUPPLEMENTAL HEALTH QUESTIONNAIRE

If you have been exposed to a communicable disease, you may spread the disease to your physician, staff, or other patients in the practice. Accordingly, prior to each appointment, we will be asking the following questions to reduce the chances of transmission. It is important that you truthfully answer each of the following questions:

  • This field is for validation purposes and should be left unchanged.

  • COVID-19 QUESTIONS

    Do you, or anyone accompanying you to today's appointment, or anyone you have recently been in contact with have any of the following symptoms?
  • I understand that if the answer to any of these questions is yes, I may be asked to reschedule my appointment to a later date.