Patient Screening

Please temporarily disable your device's Wi-Fi before continuing.

Why? A weak connection to our Wi-Fi or even the Starbucks Wi-Fi will cause the form to not submit, and we won't know that you've arrived! Thank you!

Stop here!

If you're confirming an appointment you need to use another form. Please refresh the page and click the button for confirming an appointment.

This form is only meant to be completed when you're outside our office, waiting to enter for your appointment. Please return to this page again when you've arrived.

Thank you!

Note

As a parent/guardian accompanying the patient into the office, you need to complete this questionnaire (a) once for the patient and (b) again for yourself.

If you have not already completed this questionnaire for the patient, please...

1. Change your selection above to "I am responding on behalf of the patient".
2. Complete and submit the form.
3. Click the link on the resulting page to return to this page again.
4. Complete the questionnaire for yourself by choosing "I am accompanying the patient into the office".

Thank you!

Note

If a parent/guardian is going to accompany you into the office, they will need to complete this questionnaire again for themselves.

1. Submit this form for yourself, the patient.
2. Click the link on the resulting page to return to this page again.
3. Have your parent/guardian complete the questionnaire by choosing "I am accompanying the patient into the office".

Thank you!