COVID-19 Questionnaire

Please answer the following questions before scheduling your appointment. If you have tested positive to Coronavirus or have answered yes to any of the following questions, please reschedule your appointment and follow CDC guidelines.

Full Name

Date of Birth

Have you tested positive for COVID-19 in the past 10 days?

Yes

Have you had a fever (100.0°F or greater) in the last 24 hours?

Yes

Have you had close contact with someone with a confirmed positive COVID-19 in the past 10 days?

Yes

If you have traveled out of the country within the last 10 days, did you get a negative COVID test result taken between 3 to 5 days after arrival and quarantined for 7 days?

Yes

Do you currently have any of the symptoms below? ● Fever (100.0°F or greater) or chills ● Congestion or runny nose ● Cough ● Sore throat ● Fatigue ● Headache ● Muscle or body aches ● Shortness of breath or difficulty breathing ● New loss of taste or smell ● Nausea or vomiting ● Diarrhea

Yes

If you answered YES to any of the questions above, you are NOT allowed to enter the premises.

I declare that the info I’ve provided is accurate & complete

Initials

Thanks for submitting!