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.