This form must be completed and submitted prior to each appointment. It is intended for your safety and ours. Please answer all questions truthfully and as accurately as possible. Thank you for your understanding and cooperation.
Anyone showing symptoms of COVID-19 or who may have been exposed to COVID-19 should remain home, stay away from others, and contact their healthcare provider. Please contact us to reschedule your appointment at (949) 288-3341 or email@example.com