COVID Screening

Screening for Possible COVID-19 Exposure
Patient's name*

First NameMiddle (Optional)Last Name
Date of appointment*

MonthDayYear
DO NOT complete this form if it's more than 24 hours before your appointment. If it is, you will be asked to fill it out again closer to your appointment.
Do you have a fever (greater than 100.4º F), difficulty breathing/ shortness of breath, new cough, sore throat, headache, muscle aches, chills, or loss of smell or taste?*

YesNo
Have you been exposed to someone who has been diagnosed with COVID-19 in the past 14 days? (Answer NO if you are fully vaccinated and boosted OR if you had a negative COVID test 5 to 7 days after being exposed.)*

YesNo
Have you had a positive COVID-19 test in the past 5 days?*

YesNo
If you answered YES to any of these questions, we will not be able to see you at this time. Please call our office to reschedule your appointment. If you have an urgent matter, you should have testing done at a hospital that is able to handle higher risk patients. Thank you for your cooperation.
I understand that:
1. I will be required to wear a mask or face covering throughout my time at Weinstein Imaging Associates.
2. I will not be able to have anyone accompany me into the office, except that obstetrical patients, minors, and patients who do not speak English may be accompanied by one family member.

By submitting the information below, I am electronically signing this form.
Patient's name*
Birth date*

MonthDayYear
Last 4 digits of Social Security #*
Your name and relationship, if you are the patient's personal representative
Cell phone number

Area CodePhone Number
Today's date

MonthDayYear
Should be Empty:

Screening for Possible COVID-19 Exposure