Covid-19 Pre-Appointment Survey
Please answer the following questions to help us ensure a safe appointment environment.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you experienced any of the following symptoms in the past 14 days?
*
Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
Loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea
Have you been in close contact with anyone diagnosed with COVID-19 in the past 14 days?
*
Yes
No
Have you traveled internationally in the past 14 days?
*
Yes
No
Are you fully vaccinated against COVID-19?
*
Yes
No
Submit
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