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Available Forms

COVID 19 Screening Form
Have you experienced symptoms of COVID-19 such as fever (temperature of 100°F or above) or chills, body aches, cough, shortness of breath, sore throat, nasal congestion or runny nose, nausea, vomiting, diarrhea, or loss of taste and/or smell in the past 14 days? Please answer ?yes? only if you are experiencing a new onset of symptoms OR you are experiencing a change in symptoms from baseline if you has a known pre-existing medical condition (e.g. asthma, allergies).
Is your temperature 100 degrees Fahrenheit or greater today?
Have you tested positive for COVID-19 in the past 14 days?
Have you had contact with anyone who has tested positive for COVID-19, or who have had symptoms of COVID-19, in the past 14 days?
Have you traveled internationally or to a state with widespread community transmission of COVID-19 per the NYS Travel Advisory in the past 14 days?
if you answered yes to any of the above questions, you should not come in person to the office and you should isolate yourself! Would you like to change to a telehealth appointment or cancel your appointment? (No fee will be charged if you need to cancel)
I have limited supplies and may not be able to reorder.
* Required field