Learn About Our COVID-19 Policies & Procedures – We are doing our part to keep the community and our staff safe. Read about what changes we have made.
Today's Date
Patient's name
Patient's Date of Birth
Your email
Have you received one of the COVID-19 vaccines? YesNo
Which vaccine did you receive? Moderna Pfizer Johnson & Johnson
Have you had lab diagnosed COVID-19 in the last 6 month? YesNo
- If yes when:
Do you have now, or have you had any of the following symptoms in the past 14 days? Fever or chills Dry cough, shortness of breath or difficulty breathing Fatigue Body aches Headache New loss of taste or smell Nausea, vomiting or diarrhea
Have you been or potentially been exposed to anyone with the above symptoms or a recent positive COVID-19 test? YesNo
Reminder – Mask are required to be worn while in the clinic Acknowledged Reminder – No Guests, Patients only in Clinic Acknowledged
PMSPeri-MenopauseMenopause
Pelvic Floor HealthUrinary Incontinence
Hypothyroid & Hashimoto’s Thyroiditis
Anti-AgingAge Management
Women’s Health
PCOS-Polycystic Ovarian Syndrome
Sexual Intimacy
AndopauseMale Menopause
