COVID-19 Pre-Screen Form

"*" indicates required fields

First Name*
Last Name
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Please enter a number less than or equal to 100.
Do you/they have a fever or have you/they felt hot or feverish in the past 2 weeks (14-21 days)?*
Are you/they having shortness of breath or other difficulties breathing?*
Do you/they have a cough?*

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?*

Have you/they been in contact with someone confirmed with COVID-19 in the last two weeks?*

Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.
Do you/they have any pre-existing conditions, or auto-immune disorders (i.e. Heart Disease, Lung Disease, Kidney Disease, or Diabetes)?

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