Patient Screening Form

(Please fill online and send to the office on the day of your appointment)

  • Please answer the following Screening Questions:

  • Fever:
    If “yes” to any of the above questions, please call our office before you come to your appointment. Non-emergency appointments will be rescheduled.
  • Remember when you arrive at the office, you will need to wear a mask, sanitize your hands, and have your temperature taken. Do not forget to complete our COVID-19 Risk Acknowledgement form next. Thank you.