Pre-Appointment Screening Form Please complete the following pre-appointment screening form before your appointment. Have you/they traveled in the past 14 days outside of Maryland or the US? YesNo Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)? YesNo Do you/they have a cough? YesNo Have you/they experienced any other flu-like symptoms like gastrointestinal upset, headache, fatigue, chills, or muscle aches? YesNo Have you/they experienced recent loss of taste or smell? YesNo Are you/they in contact with any confirmed COVID-19 positive patients? Are you/they well but have a sick family memeber at home with COVID-19 or other flu-like symptoms? YesNo Have you/they attended any group functions with 10 or more people? YesNo Do you/they work directly with the public as an essential employee? (I.E. Hospitals, Prisons, Grocery Stores, Assisted Living)? YesNo Have there been cases of COVID-19 where you/they are employed? YesNo Are you/they over the age of 60? YesNo Do you/they have heart disease, kidney disease, diabetes, lung disease/asthma or any auto-immune disorders? YesNo Masks must be worn upon arrival and in all common areas (restroom, hallways and frontdesk). Upon arriving at the parking lot patients will check in over the phone. Check in is needed BEFORE coming in. The waiting room is closed. All waiting is to be done outside of the office. The restroom is open but at patient's risk. Due to limited occupancy, no guests are allowed in unless medically necessary or accompanying a minor. I understand and agree to follow the policies in place due to COVID-19 mentioned above.