First & Last
Please answer the following questionnaire honestly. Knowing that you may be at risk will help us to ensure the safety of our patients and staff. Please be aware that our office is not outfitted with the required equipment to test for or treat the Coronavirus.
Approximate date you were exposed
Date quarantine ended
First and Last Name
Masks are REQUIRED for all guests 3 years and older. Please have your mask on prior to entering our offices. Masks SHOULD NOT BE REMOVED at any point.