Appointment Request

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Appointment Date

Appointment Type
Primary CareTravel MedicineDOT Physical ExamImmunizationInternal MedicineImmigration / Green Card Medical Exam

Have you or anyone in your household been tested for COVID-19?
YesNo

Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit?
YesNo

Have you traveled to a U.S. City/State with reported cases of Coronavirus in the past 30 days?
YesNo

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