New Patient Paperwork

PLEASE ANSWER THE FOLLOWING QUESTIONS BEFORE YOUR APPOINTMENT:

1. Have you tested positive for Covid-19 in the past 14 days or are you waiting for test results from a Covid-19 test?
2. Have you traveled to ANY STATE outside of Pennsylvania, or had visitors from ANY STATE outside of Pennsylvania within the last 14 days?
3. Are you or anyone in your household currently experiencing or previously experienced these symptoms in the last 14 days:
   • FEVER greater than 100°F
   • Loss of taste or smell
   • Cough with Difficulty breathing/shortness of breath
4. Have you had direct or indirect contact with anyone that is suspected OR confirmed COVID-19 positive in the last 14 days?
5. Have you had contact with anyone that has had direct contact with an individual that is suspected OR confirmed COVID-19 positive in the last 14 days?

IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, WE CANNOT TREAT YOU TODAY. YOU WILL NEED TO RESCHEDULE YOUR APPOINTMENT.

MASKS MUST BE WORN PROPERLY OVER THE NOSE AND MOUTH THROUGHOUT YOUR ENTIRE VISIT AS WELL AS IN THE WAITING ROOM AT ALL TIMES. THANK YOU FOR YOUR COOPERATION!!!