Screening Questionnaire "*" indicates required fields Patient Screening Form To be completed prior to appointment.Patient Name* First Last Guardian Name(Required if patient under the age of 18.) First Last Please note the following: Upon arrival to the office, please sanitize your hands. The receptionist will come around to check your temperature and ask the following pre-screening questions again once you are in the office. 1. Have you had any Covid 19, cold or flu symptoms in the last 7 days?* Yes No 2. Have you been in contact with any confirmed COVID-19 positive individuals in the last 5 days?* Yes No CAPTCHAEmailThis field is for validation purposes and should be left unchanged.