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* MM slash DD slash YYYY Phone Number*Upload a photo of your insurance card and IDMax. file size: 31 MB.Have you been tested for COVID-19?* Yes No What was the result? Do you have a cough?* Yes No Do you have a sore throat?* Yes No Do you have a new loss of taste or smell?* Yes No Do you have general muscle pain and/or headache?* Yes No Do you have a fever or chills now or have you in the past three days?* Yes No Are you experiencing shortness of breath?* Yes No Have you recently traveled outside the immediate area?* Yes No If you have traveled recently, to where and when? Are you caring for someone that has been tested for COVID-19?* Yes No Thank you! If we have any further questions, we will contact you. Otherwise, we look forward to seeing you at your appointment.