Patient Screening Form

Please answer the following questions.

Full Name *

Phone *

Email *

New or Existing Patient *

New

Existing

Do you have a fever or felt hot or feverish in the past 14-21 days? *

Yes

No

Are you having any shortness of breath or any difficulties breathing? *

Yes

No

Do you have any cough, sore throat, cold symptoms, stuffy nose or congestion? *

Yes

No

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? *

Yes

No

Have you experienced any loss of smell or taste? *

Yes

No

Have you been in contact with anyone COVID-19 positive patient? *

Yes

No

Have you traveled in the last 14 days outside the state of Massachusetts? *

Yes

No

Captcha