COVID-19 Screening
Last Name
Last Name is a required field
First Name
First Name is a required field
Invalid Date of Birth. Format MM/dd/yyyy
Birthdate MM/DD/YYYY
Birthdate is a required field
Have you been diagnosed with coronavirus (COVID-19)?
Yes
No
Do you have fever or had fever recently (14-21 days)?
Yes
No
Are you having shortness of breath or other difficulties breathing?
Yes
No
Do you have a cough, or have you had a cough within the last 48 hours?
Yes
No
Have you had flu like symptoms or gastrointestinal upset within the last 48 hours?
Yes
No
Have you experienced recent loss of taste or smell?
Yes
No
Have you had close contact with an individual diagnosed with COVID-19?
Yes
No
Is your age over 60?
Yes
No
Do you have heart disease, lung disease or kidney disease or diabetes?
Yes
No
Have you travelled to a country designated as Level 2 or 3 by the CDC?
Yes
No
PLEASE arrive alone with a face covering.
Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.