Pre-Appointment Wellness Form In order to maintain the health and safety of our patients and staff, it is ESSENTIAL that you complete this pre-appointment wellness form BEFORE your appointment. We appreciate your cooperation. *RequiredYour Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Phone Number*Upload a photo of your insurance card and IDHave you been tested for COVID-19?*YesNoWhat was the result?Do you have a cough?*YesNoDo you have a sore throat?*YesNoDo you have a new loss of taste or smell?*YesNoDo you have general muscle pain and/or headache?*YesNoDo you have a fever or chills now or have you in the past three days?*YesNoAre you experiencing shortness of breath?*YesNoHave you recently traveled outside the immediate area?*YesNoIf you have traveled recently, to where and when?Are you caring for someone that has been tested for COVID-19?*YesNoThank you! If we have any further questions, we will contact you. Otherwise, we look forward to seeing you at your appointment.