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Columbia

Sumter

Columbia, SC

7701 Trenholm Road Ext.
Columbia, SC 29223
(803) 736-6000

Sumter, SC

500 Physicians Lane
Sumter, SC 29150
(803) 775-4793

Doctor Referral Form
Request an Appointment

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Home
About Us
First Visit
Dental Care
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Contact

Home
About Us
First Visit
Dental Care
Questions
Contact

COVID-19 Patient Screening Disclosure

Please complete this form at least one hour before your scheduled appointment, but no more than two days prior to the date scheduled.

It is extremely important that you answer these questions accurately.

Please call or text our office after you park to let us know your specific numbered parking space. Stay in your vehicle until we call you (or come get you). Please let us know if you have any questions.

Appointment Information

Appointment Location

Columbia Sumter

Patient Information

Patient Name

Mobile Phone

Date of Birth

Vehicle Information

Vehicle Make & Model

Vehicle Color

Patient Screening

Do you have heart disease, lung disease, kidney disease, diabetes, asthma, or any auto-immune disorders?

Yes No

Do you have a fever or have you felt hot or feverish recently (14-21 days)?

Yes No

Have you experienced shortness of breath or had trouble breathing?

Yes No

Do you have a cough?

Yes No

Do you have a runny nose?

Yes No

Do you have a sore throat?

Yes No

Are you experiencing flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?

Yes No

Have you experienced a recent loss of taste or smell?

Yes No

Have you been in contact with anyone who has tested positive for COVID-19?

Yes No

Have you traveled anywhere by air, bus, or train within the past 14 days?

Yes No

Have you been tested for COVID-19?

Yes No

Additional Info

Authorization

By typing your name in the box below, you acknowledge that your answers that you provided are true and accurate to the best of your knowledge. (Please use your mouse to sign if you are using a desktop or laptop.)

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Columbia SC Office

7701 Trenholm Road Ext.
Columbia, SC 29223
803-736-6000

Sumter SC Office

500 Physicians Lane
Sumter, SC 29150
(803) 775-4793

Youtube

Columbia, SC

Sumter, SC

COVID-19 Patient Screening Disclosure

Appointment Information

Patient Information

Vehicle Information

Patient Screening

Authorization

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