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. 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
   • Sore throat
3. Have you had direct contact with anyone 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

UPDATE 6/28/21: MASKS MUST BE WORN PROPERLY OVER THE NOSE AND MOUTH THROUGHOUT YOUR ENTIRE VISIT AS WELL AS IN THE WAITING ROOM AT ALL TIMES REGARDLESS OF VACCINATION STATUS. THANK YOU FOR YOUR COOPERATION!!!