Patient Screening Form

In an effort to provide a safe environment of healthcare for you, other patients, families and our staff, please complete our COVID-19 screening form prior to your office visit.

Within the past two weeks, have you or anyone in your household experienced any of the following?
Have you been in contact with anyone tested positive with COVID-19?
Have you traveled to a designated two week quarantine state according to the Illinois Emergency Travel Order?

Thanks for submitting!