ATTENTIONATTENTION: Due to the outbreak of COVID-19, we are implementing additional safety protocols as recommended by the CDC. We ask for your cooperation in calling ahead to speak to someone, or filling out this form and waiting for one of our staff to call you if you suspect that you have been exposed to COVID-19. Please note, no vaccine or specific treatment for COVID-19 is available; care is supportive only. Please answer the following questions. Have you:* Traveled through any airports in last two weeks? Had any contact with someone with COVID-19, or suspected to have COVID-19? None of the above Do you have any of the Following Symptoms:* Fever Cough Shortness of Breath None of the Above Name* First Last Date of Birth* MM DD YYYY Phone*Email* Type of Visit Requesting*New PatientTelemedicine VisitTelephone VisitSick VisitFollow Up VisitOccupational MedicineOtherDo you need a Flu Shot at your visit?* Yes No Choose Location*Select a Location4002 Elton Way, Greensboro, NC2002 South Glenburnie Road, New Bern, NC2115 S. Main St., Suite A, Wake Forest, NC609 Richlands Hwy, Jacksonville,, NC130 Cardinal Drive, Roanoke Rapids, NC388 Venture Dr., Smithfield, NC2020 Waterscape Way, New Bern, NC275 NC 24 50 Highway, Kenansville,, NC349 Brookdale Drive, Statesville,, NC1728 North Fordham Boulevard, Chapel Hill,, NC200 Cape Fear Circle, Suite 1, Sneads Ferry,, NC154 Beulaville Highway, Richlands,, NC718 W. Corbett Avenue, Swansboro,, NC506 Hwy 301 North, Dillon, SC5130 Southport Supply Road, Southport, NC7901 Emerald Drive, Suite 7, Emerald Isle, NC325 Western Blvd, Jacksonville, NC1899 North Marine Blvd, Jacksonville, NC1033 Randolph Street, Thomasville,, NCRequested Date for Appointment* Date Format: MM slash DD slash YYYY Requested Time for Appointment*MorningAfternoonFiling Health Insurance?*YesNoNew Patient?*YesNoPhoneThis field is for validation purposes and should be left unchanged.