Pre-Appointment Screening Form

Please complete the following pre-appointment screening form before your appointment.

Have you traveled in the past 14 days outside of the United States or Maryland?
YesNo

Have you experienced any fever, cough, flu-like symptoms or a loss of taste or smell in the last 10-14 days?
YesNo

Have you had direct contact with anyone that has tested positive for COVID-19 in the last 10-14 days? Have you had direct contact with anyone experiencing flu-like symptoms in the last 10-14 days?
YesNo

Have you attended any large group functions of more than 10 people?
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.