• Have you had any of these symptoms in the last 72 hours?

    • Cough
    • Shortness of breath/difficulty breathing
    • Fever (temp >100 °F)
    • Chills
    • Repeated shaking w/ chills
    • New muscle aches
    • New sore throat
    • New loss of taste or smell
    • Nausea/vomiting/loss of appetite

    Your responses will be kept confidential. They will be reviewed by a practice clinician, who will provide guidance regarding any adjustments to your appointments.

  • Have you had any of these symptoms in the last 72 hours?

    • Cough
    • Shortness of breath/difficulty breathing
    • Fever (temp >100 °F)
    • Chills
    • Repeated shaking w/ chills
    • New muscle aches
    • New sore throat
    • New loss of taste or smell
    • Nausea/vomiting/loss of appetite

  • In the last 14 days have you had any close contact (within a distance of 6 feet, for longer than a few minutes) or taken care of anyone...

  • By signing below, I certify that I have answered all questions truthfully and to the best of my knowledge.

  • Should be Empty: