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Available Forms

COVID-19 QUESTIONNAIRE

Due to the contagious nature of COVID -19 Corona virus, we are screening patients for potential contact. Please answer the following questions each visit and click on send

Have you or any of your family members had personal contact with anyone who has any domestic or international travel in the past 21 days?
Have you had any contact with anyone diagnosed with COVID-19 Corona virus?
Please choose any symptoms you currently have
What is your first and last name?
* Required field