Patient’s Name

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

Will you use insurance?

Health InsuranceSelf-Pay

How did you find us?

GoogleFamily/FriendInsuranceDoctor RecommendationSocial MediaOther

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

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?

YesNo

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

YesNo