Coronavirus Screening Form

COVID19 screening form

Please complete no more than 48 hours of your appointment time.
Today's Date

Month Day Year
Date
Appointment Date

Month Day Year
Date
Patient's Name *

First Name Last Name
Patient's date of birth *

Month Day Year
Date
Do you have any of the following NEW symptoms in the past 48 hours? Fever or chills, new or persistent cough, shortness of breath or difficulty breathing, headache, loss of smell or taste *

Yes No
Within the past 14 days have you been in close contact (6 feet more than 15 minutes with anyone who is having symptoms of COVID OR has tested positive for COVID? *

Yes No
Have you tested positive for COVID within the past 14 days OR have you taken a test and are waiting for the results? *

Yes No
Comments
Should be Empty:

COVID19 screening form