Call Us: (717) 569-4597 Send Fax: (717) 569-2757
394 E Roseville Rd. Lancaster, PA 17601
Fever > 100.4F (38C)NoYes
Shortness of breath or respiratory symptoms?NoYes
Cough?NoYes
Exposure to a known or suspected COVID positive individual?NoYes
Change in taste or smell?NoYes
Is this your child's first visit to our practice?YesNo
First Name
Last Name
Date of Birth
In the last six months has your child had any changes in medical history, including recent hospitalizations, surgeries, or new food or drug allergies?YesNo
New medical conditionsYesNo
Please List
New medicationsYesNo
Recent Hospitalizations or ProceduresYesNo
New food or drug allergyYesNo
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