Please take this short questionnaire to help keep you and our staff safe

Instructions: Please review the questions below. If you answer yes to any of the questions, we may reappoint you for a later date.

Have you had contact with anyone confirmed positive for COVID-19 in the last 14 days?

Has anyone in your household had close contact with a confirmed or probable COVID-19 case?

Have you traveled outside of your state of residence within the last 14 days?

Is the patient waiting for COVID test results?

In the past 14 days, have you had symptoms that include:

  • Fever over 100.0°F
  • Shortness of breath or difficult breathing
  • Cough
  • Congestion or runny nose
  • Headache
  • Fatigue
  • Gastrointestinal upset
  • Nausea or vomiting
  • Diarrhea
  • Recent loss of taste or smell

Have you taken any of the following medications in the last 14 days due to a fever:

  • Acetaminophen
  • Ibuprofen
  • Naproxen Sodium
  • Aspirin

Please Call Our Office. We may need to reschedule.

Based on your responses to the questions, we need some additional information from you. Please call our office as soon as possible. If it turns out we do need to reschedule, we will find a convenient day and time for you.​

Thank you. We’ll see you at your appointment.