C0VID-19 Screening Form
Please answer the following questions…

Office protocol:

• New patients are encouraged to fill out paperwork in their vehicles if possible.
• Mouth and Nose coverings are mandatory for admission
• Guests/family of patients are encouraged to stay in their vehicles if possible.
• Upon entry please sanitize, have your temperature taken by staff and wash your hands. If you
choose to wear gloves please put them on upon entry to lessen the likelihood of contaminants
• All staff and patients are encouraged to wash hands frequently
• Signs are posted on the ceiling to ensure social distancing