COVID-19 Patient Questionnaire

As we prepare to re-open our office, we are asking out patients to fill out this quick questionnaire in order to keep you and our staff healthy and confident in the care we provide in response to COVID-19.

You can download this form and email it to: [email protected] 


Our office will be re-opening May 29th. 


For your comfort while in our care we would appreciate your help with the items listed below.

There will be a phone screen 48 hours before your appointment in regards to COVID-19.

The questions & conversation will be about:

1. COVID-19 screening

2. Changes in employment and/or insurance coverage

3. The appointment itself (confirming, time of appointment, estimated cost)

4. Office Procedures

  • We would like a call from the patient, while they are in their car, when they arrive at the office. At that time there will be another COVID-19 screening.
  • We will ask you to wait in your car until we call or text you that a room is ready. We ask that only the patient to come in, unless of course there is need, with which we can be flexible.
  • We will be doing a forehead temperature screen at the front desk.
  • We will be seating you directly in the room after the temperature check.

We realize this all seems unusual, but our goal is to keep our patients and staff safe while providing the best care we can. We can’t wait to see you back in the office!

Thank You for your understanding 

Dr Wildern and Staff