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COVID-19 Questionnaire

Consultations offered at our two convenient locations in Houston and Katy

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

YesNo

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

YesNo

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.

YesNo

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