COVID-19 Patient Screening Form
Please complete this form within 24 hours of your appointment time.
Patient's Full Name
Parent's Full Name
Have you had any of these symptoms within the last two weeks:
Loss of taste or smell
Shortness of breath
Nausea or Vomiting
Muscle aches without recognized cause
None of the above
Have you had a fever above 100.3 in the last 24 hours?
Have you been diagnosed with COVID-19 in the past two weeks?
Have you been in close contact with someone that was diagnosed with COVID-19 in the past two weeks?
What is the date and time of your appointment?
Should be Empty: