Pre-Procedure Symptom Check-In Form
Please complete this form before your upcoming procedure to help us understand your current health status.
Full Name
*
First Name
Last Name
Scheduled Procedure Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Contact Method
*
Phone
Email
Text Message
Are you currently experiencing any of the following symptoms?
*
Fever or chills
Cough
Shortness of breath
Sore throat
Muscle aches
Loss of taste or smell
None of the above
Other
When did your symptoms begin? (If applicable)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you had a fever in the past 48 hours?
*
Yes
No
Not sure
Are you currently experiencing cough or difficulty breathing?
*
Cough
Difficulty breathing
Both
Neither
Have you had any recent illness or known exposure to someone who is sick?
*
Yes
No
Not sure
Have you taken any medications today?
*
Yes
No
Please provide details of any medications taken today, or any additional information for your care team.
Submit Check-In
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