COVID Patient Questionnaire

COVID SCREENING QUESTIONS

If you answer YES to ANY of the following please call our office to reschedule your appointment.

Full Name *

Email Address *

Phone Number

Fever, Chills, Cough, Flu symptoms, other COVID symptoms, or other illness.

I have NOT experienced symptoms in the last 14 days.

I HAVE experienced symptoms in the last 14 days.

PLEASE CALL OUT OFFICE TO RESCHEDULE YOUR APPOINTMENT. (949) 313 2600

I have NOT been diagnosed with COVID-19 in the last 14 days

I have NOT been exposed to someone with COVID-19 in the last 14 days

I HAVE been exposed or diagnosed with COVID-19 in the last 14 days

PLEASE CALL OUT OFFICE TO RESCHEDULE YOUR APPOINTMENT. (949) 313 2600