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Pre-Appointment COVID Screening

*Please fill in this form no more than ONE day prior to coming into the clinic*

Do you have any of the following symptoms? Required
Have you or anyone you have been in contact with travelled outside of the country in the past 14 days?
Are you awaiting a COVID test or have you tested positive for COVID-19?

By pressing submit, I as the patient or patient's guardian state that I have, to the best of my ability, answered these questions truthfully and accurately. 

Thanks for submitting!

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