(713) 965-7224
12525 Memorial Dr. Suite 375, Houston, TX 77024

COVID-19 Questionnaire

1. Have you experienced any cold or flu-like symptoms in the past 14 days (to include fever, sore throat, cough, difficulty breathing)?


2. Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?


3. I understand that I must attend my visit alone. I agree not to bring my significant other, children, or any other individuals with me inside the suite.


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