PRE-APPOINTMENT COVID SCREENING
*The Pre-Appt COVID Questionnaire needs to be completed within 24 hr prior to every visit.

Please review the questions below carefully. If the patient is a child, please answer on behalf of the patient.


Have you (or anyone you have recently been in contact with) had any of the following symptoms in the last 14 days?


    • Fever
    • Cough, shortness of breath, or trouble breathing
    • Flu-like symptoms: such as headache, fatigue, or upset stomach
    • Loss of taste or smell
    • Rash

Have you (or anyone you have recently been in contact with) been on an airplane, cruise ship, or traveled to any state on the updated Connecticut travel advisor list in the last 14 days?


Have you (or anyone you have recently been in contact with) tested positive for COVID-19?



If the answer to ALL of the above questions is NO, please reply back to our text message the word “NO”:

Newtown: (203) 491-0290 or Monroe: (203) 491-0214


If the answer to ANY of the following questions is YES, please reply back to our text message the word “YES”:

Newtown: (203) 491-0290 or Monroe: (203) 491-0214

 

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