Please read this quick survey and click on the link below prior to your visit to help everyone stay safe and healthy!

This is currently NOT a fillable form, if you cannot answer NO to each question, please contact me before our appointment. 

1. Do you have a fever?

▢Yes ▢No

2. Do you or anyone you’ve been in close contact with have any of the following signs or

symptoms?

▢ New onset of cough ▢ Worsening chronic

cough

▢ New sore throat

▢ New shortness of breath ▢ Difficulty breathing

▢ New loss or decrease in sense of taste or smell

▢ New runny nose (not allergy-related)

▢ New sneezing (not allergy-related)

▢ Hoarse voice

▢ New nasal congestion

▢ Chills

▢ New or Unusual headache

▢ Unexplained fatigue or malaise (not due to exercise)

▢ Difficulty swallowing

▢ Nausea/vomiting, diarrhea, or

abdominal pain

3. Have you or anyone you’ve been in close contact with been on a plane, train (including the T), or bus in the last 14 days?

▢Yes ▢No

4. Have you or anyone you’ve been in close contact with traveling across state lines in the last 14 days?

▢Yes ▢No

5. Have you had close contact with anyone with respiratory illness, or a conformed or

a suspected case of COVID-19?

▢Yes ▢No

If you have answered “yes” to any question or have checked off signs or symptoms, please contact us as you may need to reschedule your appointment. If you have answered “no” to every question, please click on the link below and proceed with your appointment.

By clicking here, I confirm I have read and answered NO to these questions or will contact Shannon in advance of my appointment.