do or do not , there is no try check that box

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Patient's Name

Parent/Guardian Name

Patient/Guardian Email

Do you have a fever or have you experienced a fever within the past 14 days?

Yes

Have you experienced a recent onset of respiratory problems, such as a cough or difficulty in breathing within the past 14 days?

Yes

Have you, within the past 14 days, traveled outside the country?

Yes

Have you come into contact with a person with confirmed 2019-nCoV infection within the past 14 days?

Yes

Have you come into contact with people from confirmed cities, surrounding areas or people from a neighborhood with a recent documented fever or respiratory problems within 14 days?

Yes

I certify that the information submitted in this form is true and correct to the best of my knowledge. I further understand that any false statements may result in denial or revocation of treatment or service.

We will NEVER rent or sell your information under any circumstances. Please be advised that communications via our website or e-mail are not encrypted or sent through a secured connection. Therefore, by sending information to us electronically, understand that there is a risk of your personal information being subjected to unauthorized use by outside parties. If you have any questions or concerns, please feel free to contact us at 908-766-2444 or 973-543-6644.

COVID-19 Health Questionnaire Form