COVID 19 PYES PA Please fill out this form and submit before EVERY visit to our practice. NAME* E MAIL* PHONE NUMBER Do you have a confirmed diagnosis of COVID-19?* YES NO Have you, or anyone living with you had contact with someone with a confirmed or suspected diagnosis of COVID 19? YES NO Have you, or anyone living with you returned from overseas in the last 14 days? YES NO Do you, or anyone living with you have the following symptoms; Sore throat Cough Shortness of breath High fever Any other symptoms of illness
