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(702) 821-2000
health@westsidepediatricslv.com
8440 West Lake Mead Blvd. Suite 104 Las Vegas, NV 89128
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Your child
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Covid 19
Patient’s Name
Last Name
First Name
Patient’s Date of Birth
Email Address
COVID-19 Screening: Parent Declaration
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
Yes
No
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?
Yes
No
Are you/your child isolating or quarantining because of an exposure to a person with COVID-19?
Yes
No
Home
Our Doctor
Services
Wellness Visits
Sick Visits
Pre-operation Clearance
Sports Physicals
Adolescent Care
Your child
Newborns
First Year
Toddler/Preschool
School Age
Adolescent Care
Procedures
Circumcision
Newborn Screening
FAQs
Insurances Accepted
Dosing Information
Vaccine Schedule
Patient Education
Useful links
Contact Us
Patient Portal
