COVID-19 Self Assessment Form

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In order to ensure the safety of yourself and others, we kindly ask that you fill out this form. If you feel sick or have come in contact with anyone who has symptoms or tested positive for COVID-19, please stay home and reschedule your appointment.

Email *

Full Name *

In the last two weeks, did you have close contact with someone with symptoms of COVID-19, tested for COVID-19, or diagnosed with COVID-19 *

Yes

I don’t know

Do you have any of the following symptoms? *

Feeling Feverish (chills, sweating)

Cough

Sore Throat

Muscle or body aches

Vomiting or diarrhea

Mild or moderate difficulty breathing

New loss of taste or smell

Congestion or runny nose

None of the above

Required

Electronic Declaration *

I hereby confirm that the details above are true and correct to the best of my knowledge.

Required

A copy of your responses will be emailed to the address you provided.

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