As providers of essential medical treatments, we aim to provide a safe environment. To ensure the safety of both our patients and staff, it is critical that the information submitted in this form is as accurate as possible.
Have you experienced any of the following symptoms in the past 7 days?
In the past 7 days have you had close contact with anyone who has been diagnosed with COVID-19 or suspected to have COVID-19?
In the past 7 days have you visited any other cities/states/countries?
(For example: I went to San Antonio - Friday, Saturday, and Sunday)
In the past 7 days have you had any visitors (Family, friends, etc) from out of town?
(For example: Family members from Denver stayed the weekend)
In the past 7 days have you been to any gatherings or events which more than 5 people were in attendance?
(For example: I went to a concert where I was seated 6 feet away from people)
In the past 7 days have you visited any of the following places: