Instructions
Please complete this form on the day of your appointment, print it andbring it to your appointment.
If your answer is Yes to questions 2, 3 or 4, or if you have any of the symptomslisted in question 1, please reschedule your appointment for a day when
you are symptom-free and can answer No to questions 2, 3 and 4.
MON 10am – 6:00pm
TUES 10am – 6:00pm
WED 10am – 6:00pm
THUR 10am – 6:00pm
FRI 10am – 6:00pm
SAT 10am – 6:00pm