Screening Form for ACES

Screening Form

Please complete this form in order to book an appointment with our testing facilities or our telemedicine consultation
Name *

First Name Last Name

Have you tested positive in the past for COVID-19? *

Yes No

You must bring in proof of a negative test before you come in to the office. *

I will provide proof when I come in I don't have proof yet but I will get proof

Have you experienced symptoms in the last 14 days? *

Yes No

Have you experienced any of the following? (Check all that apply)

Fever [measured, greater than 100.4F (38C)] Subjective fever (felt feverish) Chills Cough (new onset or worsening of chronic cough) Shortness of breath (dyspnea) Flu-like symptoms Headache Diarrhea (≥3 loose/looser than normal stools/24hr period) Loss of Smell or Taste

Have you or has anyone you live with been exposed to anyone who tested positive for COVID-19? *

Yes No
Have you or anyone you live with traveled anywhere outside the country in the past couple of months? *

Yes No

Requirements for Office Visit
Do you agree to wear a mask when in public and when you visit our office? *

Yes No
Do you agree to maintain a safe distance from other people while out in public (~6 feet)? *

Yes No

Signature

Clear
By submitting I hereby confirm that the information I have given above is true, and that I will comply with the terms and conditions outlined above.
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