Office Visit Self-Check

The safety of our staff and guests is our overriding priority. As the coronavirus (COVID-19) pandemic continues, we are monitoring the situation closely and following the guidance from the Centers for Disease Control and Prevention and local health authorities. In order to prevent the spread of the coronavirus and reduce the potential risk of exposure to our staff and guests, we are asking everyone to answer these questions prior to entering the office. Please respond to these questions before entering the building.

Name*

First Last

Email*

Date of Visit*

Purpose of Visit*

Have you had any of the following symptoms in the past 14 days that you cannot attribute to another health condition: fever or feeling feverish, cough, shortness of breath or difficulty breathing, chills or repeated shaking with chills, sore throat, muscle aches/pains, headache, new loss of smell or taste, fatigue, nasal congestion/runny nose, diarrhea, nausea/vomiting, or have you or a close contact been diagnosed or presumptively diagnosed by a healthcare professional with COVID-19 in the past 14 days?*

Yes
No