Your health and wellness are our top priories. In addition to our Covid-19 precautions, we are fully vaccinated. Please fill out the questions below to help us ensure a safe environment for everyone. Thank you.
Patient Name Date
Please answer “yes” or “no” to the following questions.
Do you have any COVID-19 symptoms (fever, loss of taste/smell, shortness of breath, coughs, running nose and so on)? Yes No
Are you fully vaccinated? Yes No
Have you been diagnosed with COVID-19 in the past 10 days? Yes No Are you currently waiting for the results of a COVID-19 test? Yes No Have you traveled outside of the tri-state area within the past 14 days? Yes No If so, where?
After clicking Submit, please wait a few seconds for the data to be sent.