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.