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PATRICIA TANYA WADE MD LLC
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Available Forms
Demographics
Medical Information Release and Assignment of Benefits
Methods of Contact
New Patient Questionnaire
OFFICE POLICY FOR PATIENTS AND FAMILY MEMBERS
Pre Office visit Questionnaire
Televisit Consent Form
Terms of Receiving Test Results
Pre Office visit Questionnaire
Name
Have you traveled OUTOF STATE within the past 30 days?
*
Yes
No
Please list where you have traveled to if you answered yes.
Have you had family or friends visit you at home in the past 14 days?
Yes
No
Please check any of the boxes if you have had any of the following symptoms.If you do not answer this question your office visit will be cancelled
Fever
Cough
Sore throat
Shortness of breath
Chills
Muscle ache
Diarrhea
New loss of smell or taste
Headache
None of the above
Have you been exposed to someone who tested positive for COVID 19?
Yes
No
Have you been exposed to someone who is waiting for their COVID 19 test result?
Yes
No
Have you ever been tested for COVID 19?
Yes
No
What was the result of your last COVID-19 test?
Positive
Negative
Date of COVID-19 test:
Please upload your COVID-19 test results to the portal
* Required field
Submit Form
