How you were injured?
Date of injury:
Body Parts injured (include right or left):
Please describe how the injury occurred and where on the date you listed above:
Signature of Patient or Guardian:
All patients phone screened prior to scheduling Initial appt
Are you experiencing ANY new (or worsening) fever cough, shortness Of breath, sore throat, loss of taste/ smell, or abdominal pain/ diarrhea?
In the last 14 days, have you had contact with someone with or has confirmed COVID-19 exposure or diagnosis?
Have you travelled overseas in the past 2 weeks?
When did you get back ?:
We do require that:
Are you okay with that?
Please click on one of the three options below that does describe you