COVID-19 Patient Advisory Form

MM slash DD slash YYYY
Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?*
Are you/they having shortness of breath or other difficulties breathing?*
Do you/they have a cough?*
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?*
Have you/they experienced recent loss of taste or smell?*
Are you/they in contact with any confirmed COVID-19 positive patients? (Patients who are well but who have a sick family memeber at home with COVID-19 should consider postponing elective treatment.)*
Is your/their age over 60?*
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*
Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)*
Specific to children, have they developed any rash in the extremities in the last 14 days (in arms, legs, abdomen)?*
Have you partaken in international travel within the last 14 days?
What is your vaccination status?
If you've been vaccinated, which shot did you get?
Entering your name here is the same as submitting your signature on this document and proof of completion of this form.
This field is for validation purposes and should be left unchanged.

Airway & Sleep Group

11800 Sunrise Valley Dr.
Suite 200
Reston, VA 20191

Office Hours

Monday
7am – 4pm
Tuesday
7am – 4pm
Wednesday
7am – 4pm
Thursday
7am – 4pm
Friday
7am – 4pm
Menu