If you are experiencing any COVID-19 symptoms please contact us to reschedule your appointment.

Do you have a fever or have you experienced a fever within the past 14 days?*

Yes
No

Have you experienced a recent onset of respiratory problems, such as a cough or difficulty in breathing within the past 14 days?*

Yes
No

Have you, within the past 14 days, traveled outside the country?*

Yes
No

Have you come into contact with a person with confirmed COVID-19 infection within the past 14 days?*

Yes
No

Have you come into contact with people from confirmed cities, surrounding areas or people from a neighborhood with recent documented fever or respiratory problems within 14 days?*

Yes
No

Signature*