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About us
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Contact
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About us
Vision
Services
Doctors & Team
Office
First visit
First visit experience
Appointment request
Parent info
Forms
New patient Medical form
Medical Update (12yrs & under) form
Medical Update Teen (13 yrs +) form
SDF consent form
Appointment
Doctor Referral
New patient
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Contact
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/ Covid-19 questionnaire screening form
Form - COVID-19 Questionnaire screening
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Patient’s Full Name:
*
Parent’s Full Name:
*
Has the patient or anyone in the household tested positive or COVID19 or are self isolating due to covid?
*
Yes
No
Is anyone in your family experiencing any covid symptoms: fever, sore throat, cough, shortness of breath, extreme tiredness, upset stomach, new/unusual/long headache, loss of taste or smell or runny nose(NOT due to allergies)?
*
Yes
No
I verify the information I have provided on this form is truthful and accurate.
*
I verify the information I have provided on this form is truthful and accurate.
Date
Signature
Clear Signature
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