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

Patient Information

Vehicle Information

Patient Screening


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.)