Virtual Check-In

Virtual Check-IN

Thank you for taking the time to complete our secure online patient check-in.

If you are a minor under 18, you must have your guardian fill this out.

If you need assistance, contact our office or wait at the front door.

Patient's Full Name

Parent or Legal Guardian's Name

Patient or Legal Guardian's Phone

Have you come in contact with anyone experiencing symptoms of COVID-19 in the last 14 days?

Have you, or anyone with you, experienced shortness of breath in the last 14 days?

Have you, or anyone with you, experienced chest pressure in the last 14 days?
YesNo

Have you, or anyone with you, experienced a persistent cough in the last 14 days?

Have you, or anyone with you, had a fever in the last 14 days?

Have you, or anyone with you, been tested for COVID-19 and are awaiting the results?

Have you, or anyone with you, traveled within the USA by air, train, bus, or other public transportation in the last 14 days?

Have you, or anyone with you, traveled overseas in the last fourteen (14) days?

Have you, anyone with you, or any of your recent acquaintances tested positive for COVID-19 or any other diseases in the last 14 days?

Does the patient have any chronic immune or systemic conditions?

Is the patient older than 65?

What is your vehicle's color and make?

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