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Appointment Pre-Screening

Name

First Name

Last Name

Do you have an active cold sore?

Have you had a heart attack or stroke in the previous 6 months?

In the previous 6 months have you undergone any surgery including hip replacement, knee replacement, heart surgery?

Do you have an artificial heart valve or have a congenital heart defect?

Are you currently, or in the previous 6 months, undergoing cancer treatment, chemotherapy or radiation?

In the previous 4 weeks have you undergone cataract eye surgery?

Yes

Please complete the form above if you answer YES to any of the questions please contact our office prior to you appointment.