Patient Pre-Screening Form Patient Details

Patient Pre-Screening Form Patient Pre-Screening Form

  •  Fever greater than 100.4 degrees
  •  Shortness of breath or other breathing difficulties
  •  Have cough, sore throat, runny nose
  •  Any flu-like symptoms, such as gastrointestinal upset, headache, fatigue
  •  Recent loss of taste or smell
  •  Traveled in the past 14 days
  •  Been in contact with any confirmed COVID-19 positive patients
  •  None of the above

I will notify the office if my child develops any of the above symptoms Within 14 days post-office visit.

  •  I agree to the above statement.
(Please click below to sign)
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