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COVID19 Screening Questionnaire to Confirm Your Appointment

Dear Patient,

In the interest of SAFETY FIRST, Team Kane continues to follow COVID-19 precautions.

We require that you complete the COVID-19 screening questionnaire below prior to each office visit.

We must receive it within the next 24 hours to confirm your appointment. Without this completed form, your appointment will be canceled.

As a medical office we require employees and patients to wear a mask covering your nose and mouth during your visit. Thank you!

I actively work in a COVID-19 medical environment. (e.g. Emergency Room, COVID-19 Ward/ICU)(Required)
I had COVID-19 within the last 2 weeks.(Required)
I have been fully vaccinated.(Required)
During the 14 days prior to today or planned procedure, I have had symptoms of COVID-19 (including but not limited to: fever over 100.0 degree F without Tylenol, cough – wet or dry, shortness of breath, loss of taste or smell, loss of appetite, extreme fatigue, eye redness – conjunctivitis).(Required)
I have been within 6 feet of a COVID-19 positive individual or group.(Required)
This field is for validation purposes and should be left unchanged.