Patient Screening Form

  • Thank you for your cooperation in completing this screening form. When you arrive at the office, you will be asked to sanitize your hands, have your temperature taken and complete a form acknowledging the risk of COVID-19. Only patients can come to the office. If possible, please wait in your car until your appointment time, call the office when you arrive.

  • Date Format: MM slash DD slash YYYY
  • Screening Questions

  • Date Format: MM slash DD slash YYYY