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8440 West Lake Mead Blvd.
Suite 104 Las Vegas, NV 89128


    Patient’s Name

    New PatientEstablished Patient

    Will you use insurance?

    Health InsuranceSelf-Pay

    How did you find us?

    COVID-19 Screening: Patient & Staff Safety Is Our Top Priority

    Please select “Yes” or “No”

    Over the last 48 hours have you/your child experienced any of the following symptoms?

    Fever, cough, sore throat, shortness of breath, vomiting, diarrhea, loss of taste or smell


    In the last 14 days have you/your child been in close contact (6 feet or closer for at least 15 minutes) with anyone who had a confirmed COVID positive test?


    Are you/your child isolating or quarantining because of an exposure to a person with COVID-19