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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!

Including today and during the past 14 days, I have NOT had symptoms of COVID19 / COLD / FLU including but not limited to FEVER over 100.0 F without Tylenol, and wet or dry COUGH, SNEEZING or RUNNY NOSE.(Required)
This field is for validation purposes and should be left unchanged.