WITHIN 24 HOURS OF APPT COVID-19 SCREENER Please enable JavaScript in your browser to complete this form.Full Name *Phone *Email *Please add additional family members names here only if they have appointments and/or if they are a minor.Have you experienced any of the following symptoms in the last 24 hours prior to your appointment?Appointment(s) Day: *TodayTomorrowFever or Chills *YesNoCough *YesNoShortness of breath or difficulty breathing *YesNoMuscle or body aches *YesNoHeadache *YesNoNew loss of taste or smell *YesNoSore throat *YesNoCongestion or runny nose *YesNoNausea or vomiting *YesNoDiarrhea *YesNoHave you been exposed or advised to self-quarantine because of exposure to someone with COVID-19 in the last 14 days? *YesNoHave you been advised to self-quarantine due to traveling in the last 14 days? *YesNoIf you answered yes to any of the health screening questions, click SUBMIT + reschedule your appointment for at least 72 hours after being symptom free, without having taken fever-reducing medicine OR 14 days after exposure to a suspected or confirmed COVID-19 positive individual. If you answered no to the above screening questions, click SUBMIT and we will let you know via text when to proceed to the door for a temperature check.Signature *Clear SignatureScreening questions are provided by + required by The NJ Division of Consumer Affairs and the CDC. We are required to do a health screening and temperature check when you arrive on premises as well.Submit