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Covid-19 Prescreening Questionnaire

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Before Your Surgery Day Of Surgery After Your Surgery

Please fill out the questionnaire below TWO DAYS prior to your upcoming surgery.

Coronavirus Screening
Have you or anyone else who lives in you house been in close contact with a person with symptoms of Covid-19, been exposed to Covid-19, is being tested for Covid-19 or known to have Covid-19. *
Have you recently or currently had any fever or chills? *
Do you have any symptoms of a lower respiratory illness (cough, shortness of breath, sore throat)? *
Have you had any recent loss of smell or taste? *

For the safety of our patients we are asking that you bring only one family member or friend to bring you home who can also answer no to the above questions. As well as we would ask that your family member remain in the vehicle during your stay here until you are ready to be discharges.

If you have a mask, please bring this with you to wear prior to entering the building.

If any fever or respiratory symptoms would develop from now until the arrival of your surgery, please call our facility prior to arriving at (920) 702-8889.