COVID-19 Assessment Questionnaire
Our team is taking precautionary measures to protect you!
Please answer this form truthfully as this will help prevent
the spread of COVID-19 Virus in our community.
Risk Factor Questionnaire
History of 2019 NCoV Exposure
Thank you for submitting! Please give us time to assess.
The clinic's representative will be in contact with you prior to your scheduled visit. Should your answers to the above questions change in the interim, please advise ASAP.