(CARE CENTER) COVID-19 SCREENING QUESTIONNAIRE
In order to confirm your appointment at (CARE CENTER), we kindly ask that you complete the following.
If you answered YES to any of the above questions, please contact our office for further advice. (CARE CENTER PHONE #)
Only 1 parent is allowed to accompany patients older than 1 month of age.
To check-in for your appointment, please call our office when you arrive in the parking lot.
All persons over the age of 2 are required to wear a face mask.
I HAVE REVIEWED THE ABOVE CRITERIA. MY CHILD(REN)/DEPENDENT AND I DO NOT HAVE SYMPTOMS AS DESCRIBED. I AM CONFIRMING MY APPOINTMENT AT (CARE CENTER).