1777 Reisterstown Rd.
Suite 202 West.
Pikesville, MD 21208
(410) 602-2070

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

    I understand and agree to follow the policies in place due to COVID-19 mentioned above.