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Covid-19 Pre-Appointment Screening

Please complete this Covid-19 Pre-Appointment Screening for your up-coming appointment. 

Do you have a fever or have felt hot or feverish recently(14-21 days)?

Have you been having difficulties breathing or have been short of breath?

Do you have a cough?

Do you or have you recently had any flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Have you experienced recent loss of taste or smell?

Are you or have you been in recent contact with any confirmed COVID-19 positive patients?

Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Have you traveled in the past 14 days to any regions affected by COVID-19?

Please submit your Covid-19 Pre-Appointment Screening and a member of out staff will confirm with you that it has been received. 

Appointment Check-in will include the following NEW safety protocols:
 

We will ask you to bring and wear a face mask into the office, if you don’t have one, we will provide you one to wear during your time here.  To minimize the amount of people in the waiting room we will have you call(515-243-2412) or text(515-512-9190) the office when you arrive in the parking lot, and we will further instruct you on when to enter. At that time, we will have you use hand sanitizer, take your temperature, and ask pre-screening questions again in the office.

Thank you for your cooperation. 

Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.

Contact Us.We encourage you to contact us with any questions or comments you may have. Please call our office or use the quick contact form.