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Appointment Screening Questionnaire

TO BE COMPLETED BY ALL PATIENTS

MASKS MAY BE REQUESTED TO BE WORN IN OUR OFFICE IF RAMSEY COUNTY TRANSMISSION RATE IS HIGH.
 
 
Do you have any of the following? Fever, dry cough, shortness of breath, chills, sore throat, flu-like symptoms, or new onset of loss of taste OR smell?
 
 
Have you tested positive for COVID‐19 in the last 2 weeks?
 
 
 
Have you been in contact with someone who has tested positive for
COVID‐19 in the last 2 weeks?
IF YOU ANSWERED "YES" TO ANY OF THE ABOVE, PLEASE CALL OUR OFFICE. 651-426-8998.

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