Supplemental Health Questionnaire

* First Name:
MI:
* Last Name:
* Guardian's Name:
* Date:
* 1.     Does the patient have any of the following: fever, cough, sore throat, shortness of breath and or trouble breathing, fatigue, muscle or body aches, headache, loss of taste or smell, congestion or runny nose?
* 2.     Has the patient or the guardian accompanying the patient tested positive for COVID in the last 5 days?
3.     If you have answered yes to either of the questions, please contact the office 972-315-6100 to see if your appointment needs to be rescheduled.