COVID-19 Pre-Appointment Screening Survey Form
Please complete this brief screening survey before your appointment. Your responses will help us ensure a safe and comfortable experience for everyone.
Have you experienced any of the following symptoms in the past 14 days?
*
Fever or chills
Cough
Shortness of breath or difficulty breathing
Loss of taste or smell
Sore throat
None of the above
In the past 14 days, have you been in close contact with anyone who has tested positive for COVID-19?
*
Yes
No
Not sure
Have you traveled internationally in the last 14 days?
*
Yes
No
Are you currently awaiting the results of a COVID-19 test?
*
Yes
No
Have you received a COVID-19 vaccine?
*
Yes
No
Prefer not to say
If yes, how many doses have you received?
*
One dose
Two doses
Three or more doses
Not applicable
How would you rate your current health status?
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Do you have any additional comments or information to share before your appointment?
Submit Screening
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