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.

Patients Full Name

Parent or Legal Guardian's Name

Patient/Guardian Email

Patient/Guardian Phone

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

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

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

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

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

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

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

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

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

Is the patient older than 65?

Do you have any chronic immune or systemic conditions?

What is your vehicle's color and make?

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