Health Questionnaire

Please review and complete this form within 24 hours of your scheduled appointment

If you have answered yes to either of these questions, your appointment will be rescheduled. Thank you.

Name

First Name

Last Name

Date

YYYY

Have you tested positive for COVID-19, or been in contact with someone who has in the past 14 days?

Yes

Are you experiencing any flu-like symptoms?

Yes

If you have answered yes to either of these questions, your appointment will need to be rescheduled.