Pre-Visit Parent/Family Screening Form (MANDATORY)

Pre-Visit Screening
Has anyone had a fever or have felt hot or feverish recently (14-21 days)? *
Is anyone having shortness of breath or other difficulties breathing? *
Has anyone had a cough? *
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? *
Has anyone experienced recent loss of taste or smell? *
Has anyone been in contact with any confirmed COVID-19 positive patients? *
Are you over the age of 60? *
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? *
Has anyone traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location) *