COVID-19 Screening Form

The following questions will help us determine if a patient or family has COVID-19, symptoms of or exposure to COVID-19 or has a positive, probable or pending diagnosis.

If you answer YES to any of these questions, please contact the office as we will need to reschedule your appointment. Thank you! 

Thank you for helping us keep you safe!
 

 
 

In the past 10 days: 

Has anyone in your household traveled outside of Illinois?

Has any member of your household been exposed to someone who has been diagnosed with COVID-19 or had a positive or pending result for COVID-19?

Has anyone in your household been diagnosed with, tested for or suspected of COVID-19?

Is anyone in your household experiencing any fever, cough, shortness of breath, runny nose, sore throat, congestion, headache, new onset of vomiting or diarrhea, or complete loss of taste or smell?

Enter security code:
 Security code