Covid Screening

Please answer these additional questions to help ensure the safety of our patients and staff.

"*" indicates required fields

Name*
Date of Birth*

Are you currently experiencing any:

Coughing*
Shortness of breath*
Fever*
Chest pain or tightness*

Have you traveled out of state in the last 14 days?*
Have you been in contact with anyone who has traveled out of state in the last 14 days?*
Have you tested positive for COVID-19 in the last 14 days?*
Have you been in contact with anyone that has tested positive for COVID-19 in the last 14 days?*
Consent