Last Name
First Name
Patient’s Date of Birth:
Email Address
Please select the reason for the appointment
New PatientEstablished Patient
Phone Number
Please select the type of visit needed Wellness visitSick Visit
When would you like to book an appointment?
Preferred time of day Select TimeMorningAfternoon
Health InsuranceSelf-Pay
GoogleFamily/FriendInsuranceDoctor RecommendationSocial MediaOther
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
YesNo
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