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Covid-19 Screening Info

Please complete and return this form 48 hours prior to your scheduled appointment.

Covid-19 Screening

Name(Required)







Have you experienced any of the following symptoms in the past 48 hours:(Required)












Within the past 14 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with anyone who is known to have laboratory-confirmed COVID-19?(Required)


Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19?(Required)


Are you currently waiting on the results of a COVID-19 test?(Required)


In the past 14 days, have you traveled internationally or returned from a state identified by New York State as having widespread community transmission of Covid 19 (other than just passing through the restricted state for less than 24 hours).(Required)









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