COVID Questionnaire for In-Person Appointment

For the health and safety of our patients and staff, please complete this questionnaire 1-2 days before coming in for your IN PERSON appointment. We prefer that patients enter alone if possible. However, if you require a support person to accompany you, please have them complete this questionnaire separately.

Please wear a mask when you come to the office for your in-person appointment. There is a limit on how many patients can be in the waiting room. Be prepared to wait in the parking lot after checking in if the waiting room is at full capacity.

Thank you for your cooperation.


Only complete this questionnaire as early as two (2) days prior to your appointment.

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