Covid-19 Screen Form

For the safety of patients and staff, to limit the spread of virus, please answer the following, to the best of your knowledge. Answering "yes" to any of the following does not exclude you from an appointment.

Have you had Covid?

Have you been vaccinated against Covid?

Do you currently have, or in the past 14 days have you had...

Please select all that apply.

Have you been outside of Massachusetts in the past 14 days?

Have you had a COVID test?