In the past 14 days have you experienced any of the following symptoms? Fever >100, cough, fatigue, shortness of breath, change in taste or smell, nasal congestion, nausea or vomiting?
Have you been in close contact with someone who has tested positive for COVID-19 in the last 14 days?
What is your reason for visit?
I acknowledge that if this is a same day or next day appointment, I must complete the full online registration at time of booking to ensure my appointment does not get cancelled.
I authorize Patriot Urgent Care Professionals, PC dba AFC Urgent Care to keep my credit card on file and to charge my credit card for any balance owed, not to exceed $250. I further acknowledge that if I fail to arrive for my scheduled appointment time my credit card will be charged $50.
I understand that if I select "Self-Pay" to pay for my visit that I do not have active health insurance
In the last 14 days, have you traveled to a state considered to be high risk for COVID-19 infection?
