COVID-19 Questionnaire

Please complete and submit this form within 24 hours of your appointment. We are unable to see patients unless this form and the Supplemental Informed Consent form are received.

Patient name*
First Last
Parent/Guardian name (if applicable)
First Last
Patient/Parent/Guardian Email*
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
Please type your name below as your signature.
Patient/Parent/Guardian Signature*
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Comments
This field is for validation purposes and should be left unchanged.

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