Text “TM” or “TM Ortho” to 362867
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Safety Measures
Screening
Due to COVID-19 pandemic we need to ask you a few questions:
Question 1.
Are you experiencing any of these symptoms?
Fever? (Over 100.4)
*
Yes
No
Chills?
Yes
No
Cough?
Yes
No
Shortness of breath?
Yes
No
Headaches?
Yes
No
Diarrhea?
Yes
No
Loss sense of taste or smell?
Yes
No
Flu-like symptoms?
Yes
No
Question 2.
Have you or has anyone you live with been exposed to anyone who tested positive for CoVid-19?
Yes
No
(If Yes, Appointment must be switched to Telemedicine)
Question 3.
Have you or anyone you live with traveled anywhere outside the country in the past couple of months?
Yes
No
Question 4.
What is the recorded temperature today?
Note: If you have tested positive for CoVid19 in the past, we will need proof of a negative test before you come in to the office.
Name
*
First
Last
Date
Date Format: MM slash DD slash YYYY
Staff initials
CAPTCHA
Safety Measures
